Every finding on record at Indian Canyon Post Acute

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections, in a universe of 95 residents (Residents 1 to 95), when:1. Laundry Staff 1 (LS 1) and the Housekeeping Lead (HL) did not follow the manufacturer's guidelines for the disinfectant (DS 1) used to disinfect soiled laundry carts and soiled laundry barrels. In addition, the facility staff did not clean and disinfect the clean linen carts located in the resident hallways. This failure had the potential to cause the development and transmission of communicable diseases (an illness or infection that can spread from one person to another, or from a surface to a person) and infections to residents.2. Resident 82 who had contact isolation precautions (a set of infection control practices used to prevent the spread of germs that are transmitted by direct or indirect physical contact with a resident or the resident's environment) in place was not provided dedicated or disposable equipment such as a blood pressure cuff (an inflatable band wrapped around a resident's arm-or sometimes a thigh or wrist-to measure the resident's blood pressure), thermometer (a device used to measure the resident's temperature), stethoscope (a medical instrument used by healthcare professionals to listen to the internal sounds of a resident's body) or pulse oximeter (a device that measures the oxygen saturation level of a resident's blood and their heart rate).3. Room [room number] for Residents' 36, 21, and 59 was found with the following: 1. Under the beds there were various items had accumulated, including blankets, pillows, urine-soaked towels, tissues, food wrappers, medicine cups, ice cream cups, Styrofoam cups, straws, and dirty utensils.2. The trash can was overflowing with waste. 3. The floor was visibly dirty, covered with crumbs, sticky substances, and scattered pieces of paper. These failures had the potential to cause cross-contamination (the unintentional physical transfer of harmful bacteria, viruses, and fungi from one resident, object, or surface to another) and spread of infections to other residents, healthcare workers, and the wider Skilled Nursing Facility (SNF) environment.Findings: 1. During a Laundry Services and Facility Cleaning and Disinfection observation and interview on December 3, 2025, from 11:54 AM to 1:56 PM with the Housekeeping Lead (HL), Laundry Staff 1 (LS 1), Environmental Services Director (ESD), Certified Nursing Assistants 3, 4, 5, and 6 (CNAs 3, 4, 5, and 6) and the Infection Preventionist (IP), the HL stated that each hallway had two dirty linen receptacles which were on a plastic frame with net bags holding plastic trash bags with a plastic lid on the top. The HL stated she was responsible for cleaning and disinfecting the dirty linen receptacles on the 400 hallway but did not clean and disinfect the clean linen carts, I think the CNAs do that. The HL stated she used a disinfectant (DS 1) on the hard plastic surfaces of the dirty linen receptacles and kept the surfaces wet for 10 minutes before wiping the surface down or letting it air dry. The HL stated she sprayed the mesh bags with the DS 1 but was unable to keep the mesh bags wet for 10 minutes and she was not aware of the directions for the DS 1 indicated to use on non-porous surfaces (a material that is sealed and does not have any tiny holes, pores, or crevices) only. The HL stated when the dirty linen receptacles got full (Laundry Staff-LS- monitored the hallways hourly) the LS emptied all the full containers into a big black barrel on wheels which they took back to the laundry. The big black barrel was brought into the dirty side entryway of the laundry room where the LS donned (to put on) gown, gloves and goggles and sorted the dirty laundry into the dirty linen barrels. LS 1 joined the observation and interview and stated heavily soiled linen were rinsed and then put into the dirty sorting barrels. LS 1 stated the dirty linen was placed into the washing machines which were preprogramed for different laundry items and told the machine what detergent to use. LS 1 stated the inside of the washing machine was wiped down after each wash cycle with DS 1 which was a neutral disinfectant. LS 1 stated she let the spray set for a couple minutes and then wiped it off. LS 1 stated she did not keep the item wet for 10 minutes as she did not remember DS 1's time frame for disinfection. LS 1 stated the clean linens were loaded into the clean barrel which was disinfected with DS 1 at least once per shift as were the dirty sorting barrels and LS 1 stated she did not keep the barrels wet for 10 minutes. The barrel with clean linen was brought to the dryer and loaded into the dryer and LS 1 stated she cleaned the inside and outside of the dryer door with DS 1 but did not keep the surfaces wet for 10 minutes. The ESD joined the observation and interview at 12:31 PM, the ESD stated that surfaces need to remain wet for 10 minutes and should not be wiped before the 10 minutes were up. Additionally, DS 1 should not be used on mesh bags. LS 1 stated the laundry baskets took the clean dry clothes from the dryer to the folding table and laundry baskets were disinfected with DS 1 twice a shift and the folding table was disinfected after each load of laundry had been folded, I did not keep these surfaces wet for 10 minutes. LS 1 stated the folded laundry was stacked back into the basket and covered and taken to linen closet on the 400 hallway where the CNAs access the clean linen closet and stocked the clean linen carts. The ESD stated it was the CNAs responsibility to disinfect the covered clean linen carts in the hallways but there was no set schedule on when they should be disinfected or with what. The ESD stated the IP should know. At 1:41 PM CNAs 3, 4, 5, and 6 joined the Facility Cleaning and Disinfection observation and interview and stated they were not aware they were responsible for disinfecting the clean linen carts in the hallway and thought the housekeeping staff were disinfecting the clean linen carts. At 1:56 PM the IP joined the observation and interview, the IP stated she thought the housecleaning staff disinfected the clean linen cart weekly and did not know no one was disinfecting the clean linen carts. The IP stated the LS were required to use the disinfectant (DS 1) per the manufacturer's instructions and keep the hard non-porous surfaces wet for 10 minutes before wiping down. A review of the [Company Name] Neutral Disinfectant [DS 1] Reference Sheet, undated, indicated, Disinfection Performance in Institutions (.Nursing Homes.) . with a 10-minute contact time [the specific amount of time the product must remain visibly wet on a surface to effectively kill the pathogens (bacteria, viruses, and fungi) listed on its label], this product is effective against the following organisms on hard, non-porous surfaces: . A review of the facility's policy and procedure (P&P) titled,Cleaning & Disinfection of Environmental Surfaces, dated January 25, 2025, indicated, . 2. Non-critical surfaces will be disinfected with an EPA [Environmental Protection Agency]-registered intermediate or low-level hospital disinfectants according to the label's safety precautions and use directions. a. By law, all applicable label instructions on EPA-registered products must be followed. 3. Devices that are used by staff but not in direct contact with residents (e.g., computer keyboards, PDAs, etc.) shall be cleaned and disinfected regularly (according to facility schedule) by the environmental services staff and as needed by the nursing staff. 4. Manufacturers' instructions will be followed for proper use of disinfecting (or detergent) products including: a. Recommended use-dilution; b. Material compatibility; c. Storage; d. Shelf-life; and e. Safe use and disposal. 6. A one-step process and an EPA-registered disinfectant designed for housekeeping purposes will be used in resident care areas where: a. uncertainty exists about the nature of the soil on the surfaces (e.g., blood or body fluid contamination versus routine dust or dirt); or b. uncertainty exists about the presence of multidrug-resistant organisms on such surfaces. 7. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 8. Environmental surfaces will be disinfected (or cleaned) on a regular basis and when surfaces are visibly soiled. 2. During an observation and interview with Resident 82 on December 1, 2025, at 10:19 AM, a Contact Precautions sign, undated, posted outside Resident 82's room indicated, Contact Precautions Everyone Must: . use dedicated or disposable equipment. An isolation cart [a place to store contact precaution supplies] was located outside Resident 82's door with a sign posted to the isolation cart that indicated, Contact Isolation Precaution Cart Set-Up: . Disposable vital sign equipment . A review of the contents of the isolation cart indicated the top drawer contained two packages of instant ice pack, the second drawer contained isolation gowns, the third drawer contained more isolation gowns, the forth drawer contained two boxes of large exam gloves, and the fifth drawer contained two more boxes of large exam gloves. There was no indication of disposable or dedicated vital sign equipment. A review of the inside of Resident 82's room did not reveal disposable or dedicated vital sign equipment. Resident 82 stated the nurse brought the vital sign equipment into the room each day to take his vital sign readings. During an interview with the Interim Director of Nursing (IDON) and the IP on December 1, 2025, at 11:20 AM, the IDON and the IP confirmed that Resident 82 lacked dedicated or disposable vital sign equipment, which should have been available. A review of Resident 82's physician's order dated November 26, 2025, indicated, Order Summary: Contact isolation Carbapenem Resistant [a specific type of bacteria is not killed or inhibited by carbapenem antibiotics] Providencia Stuartii [a common bacterium found in the environment: soil, water, sewage] every shift for isolation precautions until [December 4, 2025] 23:59. A review of the facility's policy and procedure (P&P) titled, Isolation - Categories of Transmission-Based Precautions, dated January 25, 2025, indicated, Policy Statement: Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy Interpretation and Implementation: . 2. Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. A. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. B. Signs and notifications comply with the resident's right to confidentiality or privacy. 6. When transmission-based precautions are in effect, non-critical resident-care equipment items such as a stethoscope, sphygmomanometer [blood pressure cuff], or digital thermometer will be dedicated to a single resident (or cohort [group] of residents) when possible. 3. During an observation on December 1, 2025, at 11:22 AM, in Room [room number], the room was found with the following: 1. Under the beds there were various items had accumulated, including blankets, pillows, urine-soaked towels, tissues, food wrappers, medicine cups, ice cream cups, Styrofoam cups, straws, and dirty utensils. 2. The trash can was overflowing with waste. 3. The floor was visibly dirty, covered with crumbs, sticky substances, and scattered pieces of paper. During an interview on December 1, 2025, at 11:24 AM, with Resident 36, he stated the room had not been cleaned and the trash had not been removed for the past three days. Resident 36 further stated that due to his medications, which include diuretics (medications that increase the production of urine), he frequently urinates in towels because his urinal fills up quickly, and staff are not quick enough to dump it. Subsequently, he places these urine-soaked towels on the floor to avoid soiling his bed. Resident 36 further stated he uses tissues to wipe his nose and discards them on the floor due to the trash can being full and overflowing. During an interview on December 1, 2025, at 11:26 AM with Resident 21, he stated, They did not clean my room for days now, look! pointing to the floor and under his bed.During an interview on December 1, 2025, at 11:28 AM, with Resident 59, he stated, Last time this room was cleaned was Friday morning. No one came to sweep and mop the floor over the weekend. Hopefully someone will come clean it today, but I haven't seen any housekeeper yet. During an interview on December 1, 2025, at 11:30 AM with Certified Nurse Assistant 3 (CNA 3), CNA 3 stated room [room number] is dirty because the housekeeping staff did not clean the room and did not remove the trash over the weekend. CNA 3 further stated housekeeping had not been seen cleaning the room on the day of the interview either. During an interview with the Environmental and Maintenance Services Director (EMSD) on December 2, 2025, at 9:20 AM, the EMSD acknowledged that the scheduled housekeeper did not clean the room this past weekend. The EMSD stated every room in the facility gets cleaned and moped at least once a day, sometimes multiple times depending on the residents' needs and housekeepers are expected to revisit and clean rooms that become messy throughout the day. The EMSD explained that the housekeeper 3 (HH 3) who is responsible for the cleanliness of rooms in 300-hall, was previously identified to have work performance deficiencies in the past and appropriate action was taken. The EMSD acknowledged that the room should have been cleaned and moped daily, and his expectations are that all housekeeping staff follow the daily cleaning schedule and facility's policy and procedures. HH3 was not available for interview. During an interview with the facility's Infection Preventionist (IP) on December 2, 2025, at 3:32 PM, the IP stated that her expectations are for the facility to be always maintained clean and for the staff to adhere to the daily cleaning schedule and follow facility's policies and procedures. During an interview with the Operations Manager (OP) on December 3, 2025, at 1:58 PM, the manager specified that residents' rooms are required to be cleaned daily in accordance with the cleaning schedule and additionally as needed if they become dirty after the scheduled cleaning. The OP stated all staff must adhere to the facility's policies and procedures (P&P) to ensure a clean and sanitary environment for residents, staff, and visitors. During a concurrent interview and record review on December 4, 2025 at 9:49 AM, with EMSD, the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces revised January 25, 2025, was reviewed. The P&P indicated, Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard.1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care and those in the resident's environment: . c. Non-critical items are those that come in contact with intact skin but not mucous membranes: c1. Non critical environmental services include bed rails, some food utensils, bedside tables, furniture and floors. 2. Non critical services will be disinfected with an EPA-registered intermediate or low-level hospital that's infected according to the label's safety precautions and use directions . 6. A one-step process and an EPA-registered disinfectant designed for housekeeping purposes will be used in resident care areas where: a. Uncertainty exists about the nature of the soil on the surfaces (e.g. blood or body fluid contamination versus routine dust or dirt); or b. Uncertainty exists about the presence of multidrug resistant Organism on such surfaces. 7. Housekeeping surfaces (e.g. Floors, tabletops) will be clean on a regular basis when spills occur and when these surfaces are visibly soiled. 8. Environmental surfaces will be disinfected (or cleaned) on a regular basis and when surfaces are visibly soiled . 10. Disinfecting (or detergent) solutions will be prepared as needed and replaced with fresh solution frequently .13. Spills of blood and other potentially infectious materials will promptly be cleaned and decontaminated. Blood containment items will be discarded in compliance with federal regulations (i.e. OSHA Bloodborne Pathogens Standard). 14. If the spill contains large amounts of blood or body fluids, the visible matter will be cleaned with disposable absorbent material, and the contaminated materials discarded in an appropriate, labeled container. The EMSD acknowledged the facility's P&P were not followed when room [room number] was found with various items accumulated under the beds, including blankets, pillows, urine-soaked towels, tissues, food wrappers, medicine cups, ice cream cups, Styrofoam cups, straws, dirty utensils, trash can overflowing with waste, visibly dirty floor covered with crumbs, sticky substances, and scattered pieces of paper. The EMSD admitted the dirty conditions in room present infection control issues, particularly to vulnerable residents, and acknowledged that the cleanliness standards were not met according to facility's P&P.

Based on observation, interview, and record review, the facility failed to provide interpretive services to residents including Resident 45, whose primary language is other than English.This failure had the potential to compromise residents the ability to understand, comprehend, and effectively communicate their needs, rendering them unable to fully participate in their plan of care, likely leading to residents experiencing diminished self-esteem, social interaction withdrawal, and significant emotional distress.Findings:During an interview conducted on December 1, 2025, at 11:36 AM with Resident 45, it was revealed that Spanish is Resident 45's primary language, and he does not speak or understand English. Although he could respond to simple Yes/No questions spoken in English, he did so with visible hesitation and reservation. Resident 45 utilized his cell phone to contact his daughter, who subsequently assisted as a translator through the phone's speaker.Through his daughter's translation, Resident 45 communicated his frustration with being unable to convey his needs and preferences to the staff due to the language barrier. He expressed feeling more comfortable when Spanish-speaking staff members are available. However, he is not always assigned to Spanish-speaking staff due to staffing variances. This inconsistency in communication had contributed to his feelings of frustration and unease during his stay at the facility. Resident 45 indicated a strong preference for the facility to provide an interpreter to facilitate better communication and dialogue with staff members. He emphasized that having an interpreter would greatly enhance his overall experience through direct dialog with staff, ensuring that his needs and concerns are adequately addressed in a timely manner. A review of residents' 45 face sheet (a facility document that contains basic information about the resident) indicated he was admitted at the facility on January 7, 2025, with diagnoses which include hemiplegia with hemiparesis [weakness (hemiparesis) on one side of the body, ranging from mild to severe, often accompanied by complete paralysis (hemiplegia) on the same side, typically affecting the arm, leg, and sometimes face, due to brain injury disrupting nerve signals] following cerebral infarction affecting right dominant side, aphasia (disorder caused by brain damage that affects a person's ability to communicate by interfering with their speech), unspecified intracranial injury (damage to the brain or its surrounding structures inside the skull) without loss of consciousness, lack of coordination, type 2 diabetes, neuropathy (nerve damage or disease, often in the hands and feet, that causes symptoms like numbness, tingling, burning pain, or muscle weakness), chronic kidney disease stage 4 (kidneys have severe damage and function at only 15-29% of normal), hypertension (high blood pressure), and major depressive disorder(a mood disorder characterized by persistent feelings of sadness and a loss of interest in activities).A review of the Comprehensive Material Data Sheet (MDS - contains demographic information, resident assessment and care screening) dated September 26, 2025, identified Resident 45 ethnicity as Hispanic and noted that his preferred language is Spanish, requiring an interpreter for communication with medical or healthcare staff.A review of the Resident 45's Care Plan indicated, the resident has a communication problem related to a language barrier, impaired hearing, neurological symptoms, impaired cognition, depression, and aphasia. However, there are no interventions addressing the language barrier.During an interview with Licensed Vocational Nurse 4 (LVN 4) on December 1, 2025, at 3:22 PM, LVN 4 indicated that the facility does not provide interpretive services for residents who do not speak English. LVN 4 further stated that she utilizes the Google Translate App on her personal cell phone to communicate with these residents.During an interview with the Social Services Director (SSD) on December 1, 2025, at 3:49 PM, the SSD confirmed that the facility does not offer translation services for non-English speaking residents. The SSD further explained that she relies on staff members for translation when they are available and uses a translation application on her phone to communicate with residents when staff assistance is not accessible.During a concurrent record review and interview with the (SSD) on December 1, 2025, at 4:03 PM, the SSD confirmed that Resident 45 needs an interpreter to effectively communicated with staff. The Policy and Procedure (P&P) titled, Translation and/or Interpretation of Facility Services, undated, was reviewed with the SSD. The P&P states . 8. Competent oral translation of vital information that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means as available to the facility: . c. Contracted interpreter service; d. Voluntary community interpreters who are trained and competent in the skill of interpreting; and e. telephone interpretation service. The SSD acknowledged that the facility lacked interpreter services as of December 1, 2025, and agreed the facility's P&P was not followed. During an interview with the Operations Manager (OP) on December 3, 2025, at 8:58 AM, the OP acknowledged that the facility did not ensure non-English speaking residents could communicate effectively with staff through an interpreter as per the facility's policies and procedures.During an interview with the Director of Nursing (DON) on December 4, 2025, 11:33 AM, the DON acknowledged that non-English speaking residents were unable to effectively communicate with staff and participate in their plan of care due to facility's failure to provide interpreter services as specified in facility's policy and procedure. The DON recognized that consistent provision of language support would not only enhance residents' comfort but also promote a more inclusive and supportive environment within the facility.During a follow-up interview with the Social Services Director (SSD) on December 4, 2025, at 2:22 PM, the SSD confirmed that a total of eight non-English speaking residents currently residing at the facility require interpreter services to effectively communicate with staff and participate in their plans of care. The SSD acknowledged that as of December 1, 2025, the facility lacked adequate interpreter services to meet residents' needs.

Based on interview, and record review, the facility failed to act promptly upon the resident council's grievances and recommendations when the Grievance Official (GO) failed to address or provide a rationale for the inability to act on the resident council's grievances and recommendations over a three-month period (August 2025 to October 2025) for 16 sampled residents (Residents 1 to 16). This failure had the potential to cause an undermining of residents' independence, a hindering of effective problem resolution and quality improvement, and ultimately creating an atmosphere of fear and distrust within the facility.Findings:During the entrance conference with the Interim Director of Nursing (IDON) on December 1, 2025, at 9:30 AM, the IDON stated Resident 41 was the resident council president.During an interview with Resident 41 and the Administrator (Admin) on December 1, 2025, at 3:17 PM, Resident 41 stated he was no longer the president of the resident council because he felt it was a waste of time since the facility never addressed the concerns raised by the council. The Admin stated the resident council president was Resident 19.During an interview with Resident 19 on December 1, 2025, at 3:28 PM, Resident 19 confirmed he was the resident council president and the group met about once per month. Resident 19 granted permission for a review of the resident council's meeting minutes over a three-month period.A review of the resident council meeting minutes dated August 2025, September 2025, and October 2025, was conducted. The following is a summary of the documented grievances and recommendations:Physical Therapy (PT): PT not doing enough, More PT not just once per week, resident not getting walks, PT for all body parts, an open gym for exercise.Nursing: Coming in turning call light off and walk back out again, staff complaining about getting things from the kitchen, not cleaning well after toilet use, sugar drop in independent residents and no one checks. Medications on time and correct medications, listen and respond to resident concerns, night shift nurses sleeping on the job and not providing showers.Dietary: More options for meal substitutions, more variety for daily meals, more variety for nighttime snacks, hot cereal not made correctly.Housekeeping: Clean the rooms better. Only cleaning bathroom not room itself, more clothes for men, more linen. Laundry to return correct clothes to the correct residents.Administration: listen and be more responsive. Operations Manager (OM) to attend meetings to understand residents' concerns. A resident council meeting was conducted on December 2, 2025, from 10 AM to 10:45 AM, 16 residents attended the meeting including the former president, Resident 41, and the current president, Resident 19. A summary of the documented grievances and recommendations from the resident council meetings held in August 2025, September 2025, and October 2025, was reviewed with the attendees. The attendees were asked whether the facility had addressed or responded to the council's grievances and recommendations for this three-month period. Approximately 50 percent of the attendees, including Residents 41 and 19, indicated that the facility had neither responded to nor addressed the council's grievances and recommendations during this three-month period.During an interview with the Admin on December 3, 2025, at 7:42 AM, the Admin stated the Grievance Official (GO) was the Social Services Director (SSD). The Admin stated the GO acted upon the resident council's grievances and recommendations.During an interview with the GO and the Activities Director (AD) on December 4, 2025, from 7:18 AM to 7:37 AM, The GO confirmed her role and responsibilities and stated that it was her responsibility to address grievances and recommendations from resident council meetings. However, the GO stated that the activities director had not provided her with minutes from these meetings for approximately six months, preventing her from addressing any issues or suggestions raised by the residents. The Activities Director (AD) stated she assumed her position in July 2025. The AD stated that no orientation or training was provided for the AD role, and she was unaware of the requirement to forward the resident council meeting minutes to the GO for action. The AD stated she handwrote the minutes for the resident council meetings and acknowledged the grievances and recommendations raised. The AD verbally communicated these issues to the Operations Manager (OM), the IDON, and the Dietary Services Supervisor (DSS), but noted that since it was not documented in writing, those individuals likely forgot. The GO stated that she could not adhere to the facility's policy and procedure titled Grievances, dated January 25, 2025, as she had not received the grievances and recommendations from the resident council meetings.During an interview with the OM and the Admin on December 4, 2025, at 8:04 AM, The OM and Admin stated it was the responsibility of the AD to provide the resident council meeting minutes to the GO, and it was the GO's responsibility to act upon the grievances and recommendations documented in the meeting minutes. The OM and Admin stated the facility had not acted promptly upon the resident council's grievances and recommendations. A review of the facility's policy and procedure (P&P) titled, Grievances, dated January 25, 2025, indicated, Policy: It is the policy of this facility to establish a grievance process to 1. Address resident concerns without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their facility stay; and 2. Make prompt efforts to resolve grievances the resident may have. Procedures: 1. The facility's grievance official is responsible for overseeing the grievance process, receiving and tracking grievances; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident, if requested; and coordinating with state and federal agencies as necessary. 2. Resident and/or Resident Representatives have the right to file grievances orally or in writing, . 3. General concerns may be voiced at Resident Council meetings. 4. The Grievance Official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations of any resident's right while the alleged violation is being investigated. 6. The Grievance Official or designee responds to the individual expressing the concern within (3) three working days of the initial concern to acknowledge receipt and describe steps taken toward resolution.

Based on observation, interview, and record review, the facility failed to provide special eating equipment in the form of an adaptive drinking aid for one sampled resident (Resident 89) when Resident 89, diagnosed with dysphagia (difficulty swallowing), was provided regular standard straws to drink thin fluids instead of a nosey cup (a cup with a U-shaped cutout on one side of the rim, which provides clearance for the nose and allows individuals to drink fluids without tilting their head or neck backward) during his lunch time meal. This failure had the potential to cause Resident 89 to choke, as standard straws deliver liquids quickly and encourage a head-back position that opens the airway. In contrast, the nosey cup encourages a chin-tucked position, reducing the risk of aspiration pneumonia an infection from fluids entering the lungs.Findings:A review of Resident 89's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of October 3, 2023. Resident 89 had diagnoses that included dysphagia.During a dining observation and interview with a Certified Nursing Assistant 1 (CNA 1) and Resident 89 on December 1, 2025, at 12:28 PM, Resident 89 was seated at a table in the dining room, and CNA 1 was helping him eat his lunch. A meal card on the table indicated that Resident 89 should use a nosey cup. However, he had a small milk carton with a regular straw and a regular cup of juice covered with cellophane, also with a regular straw poked through. CNA 1 helped Resident 89 drink using these regular straws and stated that Resident 89 did not have a nosey cup, but she did not know why.During an interview with the Dietary Supervisor (DS) on December 1, 2025, at 12:35 PM, the DS confirmed that Resident 89's meal card specified the use of a nosey cup, but this had not been provided. The DS acknowledged that she had not informed the Interim Director of Nursing (IDON), Resident 89's physician, or the Director of Rehabilitation (Dir/Rehab) that Resident 89 had declined and was no longer holding the nosey cup. In addition, the DS admitted to substituting regular straws without obtaining an Occupational Therapy (OT) assessment for straw use or requesting nursing staff to obtain a new dietary order from Resident 89's physician.A review of Resident 89's physician's order dated January 8, 2024, indicated, . nosey cup .During an interview with the IDON on December 1, 2025, at 12:40 PM, the IDON stated she had not been informed of Resident 89's decline and the subsequent need for a new OT evaluation for adaptive equipment, as well as a new physician's order reflecting the recommendations from the new OT evaluation. During an interview with the Dir/Rehab on December 4, 2025, at 10:51 AM, the Dir/Rehab stated Resident 89 should have been re-evaluated before replacing the nosey cup with regular straws, and a new physician's order reflecting the re-evaluation findings should have been obtained. The Dir/Rehab confirmed that her department had not been informed, and no re-evaluation of Resident 89's eating and drinking needs had been conducted.A review of the facility's policy and procedure (P&P) titled, Occupational Therapy . Evaluation and Recommendation of Feeding Adaptive Devices, undated, indicated, I. PURPOSE: To ensure safe, appropriate, and clinically justified evaluation, selection, and recommendation of feeding adaptive devices for residents who have functional limitations affecting self-feeding . III. POLICY STATEMENT: Occupational Therapy will evaluate residents with difficulty in self-feeding and recommend adaptive feeding equipment when clinically indicated. All recommendations will be evidence-based, individualized, documented, and coordinated with the interdisciplinary team (IDT). IV. PROCEDURE: A. Referral and Screening, A feeding adaptive device evaluation may be initiated through physician, nursing, dietary referral, or OT observation. B. Occupational Therapy Evaluation: Complete a comprehensive self-feeding evaluation including ROM [Range of Motion], strength, coordination, posture, cognition, and vision. Review SLP [Speech Language Pathologist] recommendations, IDDSI [International Dysphagia Diet Standardization Initiative] diet, and swallowing safety. Assess environmental factors such as seating, table height, and lighting. Trial appropriate adaptive feeding devices. C. Recommendation and Implementation: Device selection must be based on functional abilities and goals. Educate resident, caregiver, nursing staff, and family. Notify nursing and dietary of device recommendations. D. Documentation Requirements: Document evaluation findings and clinical justification. Devices trialed and resident response. Final recommendations and goals. Education provided and care plan updates.

Based on interview, and record review, the facility failed to provide evidence it received, documented, and acted upon pharmacist recommendations of monthly medication regimen reviews (a pharmacist evaluation of a patient's entire medication regimen with recommendations in order to identify potential problems with ineffective drugs, harmful interactions, incorrect dosages etc.) for one of five residents (Resident 8) reviewed for unnecessary medications.This failure resulted in Resident 8 to be at increased risk for irregularities in the resident's medication regimen to go unidentified and uncorrected which could result in adverse drug effects and avoidable negative outcomes for the resident.Findings:During a review of Resident 8's admission Record (contains medical and demographic information), the admission Record, indicated Resident 8 was initially admitted to the facility on [DATE], with diagnoses which included hypertensive heart disease (heart problems that occur because of high blood pressure present over a long period of time), major depressive disorder (a serious mood disorder causing persistent sadness, loss of interest, and significant impact on daily life), anxiety disorder (a condition characterized by excessive fear or apprehension), and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions).During a review of the facility document titled, Current Resident Listing for [name of the facility] with Medication Regimen Review activity between 9/1/25 and 9/27/25, (a document which indicates which residents' medication regimens were reviewed by the consultant pharmacist for the month of November) dated November 27, 2025, the document included the name of Resident 8 indicating the pharmacist did perform a review of Resident 8's medications for September 2025.During a review of the facility document titled, Consultant Pharmacist's Medication Regimen Review: Listing of Residents Reviewed with No Recommendations, dated September 1, 2025, through September 27, 2025, the document did not include the name of Resident 8 which meant the pharmacist had recommendations regarding Resident 8s medication regimen for September 2025.During a review of the facility document titled, Current Resident Listing for Indiana [Indian] Canyon Post Acute with Medication Regimen Review activity between 8/1/25 and 8/27/25, dated August 27, 2025, the document included the name of Resident 8 indicating the pharmacist did perform a review of Resident 8's medications for August 2025.During a review of the facility document titled, Consultant Pharmacist's Medication Regimen Review: Listing of Residents Reviewed with No Recommendations, dated August 1, 2025, through August 27, 2025, the document did not include the name of Resident 8 which meant the pharmacist had recommendations regarding Resident 8s medication regimen.During a review of Resident 8's electronic medical record, the pharmacist's recommendations regarding Resident 8's monthly medication regimen review for September 2025 and August 2025, was not found.During an interview on December 4, 2025, at 1:30 PM, with the Director of Nursing (DON), Resident 8's consultant pharmacist medication regimen review recommendations for September and August of 2025, were requested. The DON stated she was unable to find evidence of the pharmacist's recommendations for Resident 8's medication regimen review for September and August of 2025. The DON further stated she usually printed the pharmacist recommendations and provided them to the medical records department for follow up but states they were unable to find the recommendations. The DON further stated the consultant pharmacist would have sent her recommendations for Resident 8 for September and August of 2025 since the resident was not on the no recommendations lists for those months.During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Review (MRR), dated January 25, 2025, the P&P indicated, 1. The drug regimen of each resident, which includes a review of the resident's medical chart; will be reviewed at least once a month by a licensed pharmacist; 2. Irregularities will be documented on a separate written report; that is sent to the attending physician, the facility's medical director and the director of nursing services and lists the resident's name, the relevant drug, and the irregularity the pharmacist identified. These reports will be acted upon. Procedure: 1. The pharmacist reviews each resident's medication regimen at least once a month in order to identify irregularities and to identify clinically significant risks and/or adverse consequences resulting from or associated with medications.

The facility failed to ensure that physician's orders were followed for one of one resident (resident 11) reviewed for antibiotic use when the monitoring and documentation of intake and output (I&O) was not done as ordered by the physician.This failure resulted in an incomplete assessment and monitoring of Resident 11's hydration status and fluid balance while on the antibiotic (medication used to treat infections). Findings:A review of Resident 11's admission Record (contains medical and demographic information), indicated Resident 11 was admitted to the facility on [DATE], with diagnoses which included pneumonia (a lung infection), quadriplegia (paralysis affecting all four limbs), Chronic Obstructive Pulmonary Disease (a condition involving constriction of the airways and difficulty in breathing).During a review of Resident 11's care plan (an individualized plan for the medical care of a resident) titled, The resident has a Urinary Tract Infection r/t cloudy urine, lethargy (lack of energy) and generalized malaise (an overall feeling of being unwell), dated November 11, 2025, the care plan indicated, Goal.the resident will be free of symptoms of dehydration.Interventions.Encourage adequate fluid intake.During a review of Resident 11's care plan titled, The resident has potential for fluid deficit r/t [related to] PNA [pneumonia], dated October 4, 2025, the care plan indicated, Goal.The resident will be free of symptoms of dehydration.Interventions.Administer medications as ordered. Monitor/document for side effects and effectiveness. Educate the resident/family//caregivers on importance of fluid intake.Monitor/document/report PRN [as needed] any s/sx [signs and symptoms] of dehydration: decreased or no urine output.During a review of Resident 11's physicians orders, an order dated November 11, 2025, indicated Ertapenem sodium injection [an antibiotic] Solution reconstituted [the process of adding a diluent or solvent to a dry, powdered, or concentrated medication to create a usable liquid solution or suspension for administration] inject 1 gram [gm -unit of measure] intramuscularly [administered into the muscle] one time a day for UTI [urinary tract infection] for 5 [five] days with lidocaine [a numbing agent].During a review of Resident 11's physicians orders, an order dated November 12, 2025, indicated Monitor intake and output every shift for antibiotic use until 11/16/2025 [November 16, 2025].During a review of Resident 11's intake and output record titled, Documentation Survey Report V2, dated November 2025, the document indicated intake volumes were not documented by staff for three of ten (3 of 10) shifts between November 12, 2025, and November 16, 2025. Additionally, there was no output documentation found anywhere in Resident 11's medical record for the ten shifts between November 12, 2025, and November 16, 2025.During a concurrent interview and record review on December 3, 2025, at 2:47 PM, with the Director of Nursing (DON), Resident 11's intake and output record titled, Documentation Survey Report V2, dated November 2025, was reviewed. The DON acknowledged there were three of ten shifts where intake was not documented. Additionally, the DON acknowledged there was no output documentation noted for any of the ten shifts from November 12, 2025, through November 16, 2025. The DON stated nursing staff were supposed to document intake and output each shift as ordered by the physician, but they had not.During a concurrent interview and record review on December 3, 2025, at 2:48 PM, with the Corporate Medical Records Staff (CMR), Resident 11's entire electronic health record (EHR) was reviewed. The CMR acknowledged there were three shifts between November 12, 2025 and November 16, 2025, where input was not documented. The CMR stated output was not documented at all by staff, but should have been.During a review of the facility's policy and procedure (P&P) titled, Intake and Output, revised January 2025, the P&P indicated, It is the policy of this facility to maintain an intake and output record when needed to monitor residents for adequate fluid balance.Intake and output shall be recorded by each shift .

Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 3) reviewed for pressure ulcers (injury to skin and underlying tissues that develops as a result of prolonged pressure, shear, or friction) had a low air loss mattress (LAL mattress - a specialized mattress which is air filled and is designed to help prevent and treat pressure ulcers) which was programmed to Resident 3's weight.This failure resulted in the low air loss mattress to not have the most therapeutic effect for the prevention and treatment of pressure ulcers and for Resident 3 to have increased risk for the development of new pressure ulcers and a delay in wound healing.Findings:A review of Resident 3's admission Record (contains medical and demographic information), indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included heart failure, methicillin resistant staphylococcus aureus infection (an infection caused by an antibiotic-resistant bacteria), diabetes mellitus type 2 (a metabolic disorder characterized by persistent high blood sugar levels), and cellulitis of the left and right lower limbs (a bacterial infection of the skins deeper layers and underlying tissues).During a concurrent observation and interview on December 1, 2025, at 10:58 AM, Resident 3 was lying in bed on a low air loss mattress. The mattress was set to 360 pounds (lbs - unit of measure). Resident 3 stated he weighed approximately 275 lbs and that he was on the LAL mattress because he occasionally had bed sores and pressure ulcers.During a concurrent observation and interview on December 1, 2025, at 11:03 AM, with the Interim Director of Nursing (DON), the DON reviewed Resident 3's Electronic Health Record (EHR) and stated Resident 3 weighed 276 lbs. The DON stated the setting of the LAL mattress was supposed to be according to the physician's order and if there was no specific setting indicated in the physician's order, it was supposed to be set to the resident's body weight. The DON reviewed Resident 3's order for the LAL mattress and stated since there were no parameters for settings in the order, Resident 3's LAL mattress was supposed to be set to his body weight. The DON further stated the LAL mattress and its appropriate use was important to help prevent skin breakdown and to promote healing of wounds.During a concurrent observation and interview on December 1, 2025, at 11:08 AM, with the DON, Resident 3's LAL mattress was observed to be set to 360 lbs. The DON acknowledged the mattress was set to 360 lbs and stated the mattress was supposed to be set to 240 lbs. The DON then showed a label on the LAL mattress unit which stated Setting 240. The DON stated 240 lbs was the closest selectable level to the residents weight of 275 lbs. The DON further stated the wound care nurse puts the label on each LAL mattress to ensure the staff know what weight it was supposed to be programmed to. The DON stated she was not sure why Resident 3's LAL mattress was set incorrectly.During a review of Resident 3's EHR, the residents most recent weight documented in the vitals and weights portion of the EHR was recorded as 276 lbs on November 9, 2025.During a review of Resident 3's physician's orders, an order dated October 28, 2025, indicated, Low air loss mattress for itssue [tissue] load management, check placement, motor and setting every shift.During a review of Resident 3's care plan (an individualized plan for the medical care of a resident) titled, At risk for regression related to admitted with multiple pressure injuries, vascular ulcers.episodes of refusing to reposition, noncompliance with turning and repositioning and off loading of bilateral leg Dated October 28, 2025, the care plan included the intervention, Administer treatments as ordered and monitor for effectiveness.LAL mattress to promote tissue load management.During a review of Resident 3's Treatment Administration Record (TAR - a document used to record treatments administered to the resident), dated November 2025, the TAR indicated a task for, Low air loss mattress for itssue [tissue] load management, check placement, motor and setting every shift. For 26 out of 27 shifts between November 1, 2025, through November 30, 2025, staff documented that the LAL mattress was set to between 360 lbs and 370 lbs. Additionallyu, three shifts had blanks and were incomplete.During a concurrent interview and record review on December 3, 2025, at 2:35 PM, with the DON, Resident 3's TAR dated November 1, 2025, through November 30, 2025, was reviewed. The DON stated the nurses were supposed to document the current LAL mattress setting on the TAR and acknowledged the setting documented was between 360 and 370 lbs and was incorrect because the resident weighed 275 lbs in November 2025. The DON further stated nurses were supposed to be monitoring the residents weight and ensuring the LAL mattress was set per the residents weight, but it was not done.During a review of the facility's policy and procedure (P&P) titled, Low Air Loss, Alternating Pressure Pad or Mattress, dated January 2025, the policy indicated, It is the policy of this facility to prevent and treat pressure ulcers, alternate pressure under bony prominences and provide resident comfort.4. Low Air Loss mattress will be set up and serviced according to manufacturer's recommendations.During a review of the manual for Resident 3's low air loss mattress titled, [brand name] Operation Manual for Protekt Aire 4000DX/5000DX, (undated), printed December 1, 2025, the operators manual indicated, The Protekt Aire 4000DX/5000DX system is intended to reduce the incidence of pressure ulcers while optimizing patient comfort.Product Function.Press up or down buttons to select the correct patient weight.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan to ensure Resident 89's optimal physical, mental, and psychosocial well-being when Resident 89 displayed a behavior of aggressively chewing on the thumb and first three fingers of the left hand, and the first two fingers of the right hand.This failure resulted in damage to the fingernails on Resident 89's left hand.Findings:A review of Resident 89's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of October 3, 2023. Resident 89 had diagnoses that included Alzheimer's disease (a progressive type of brain disease and is the most common cause of dementia) and dementia (an umbrella term for a collection of symptoms, such as memory loss, language problems, and impaired thinking skills, severe enough to interfere with daily life).During an observation and interview with Resident 89, Certified Nursing Assistants 2 and 3 (CNA 2 and 3) on December 1, 2025, from 4:05 PM to 4:35 PM, Resident 89 was in his room in bed and was wearing a short sleeve hospital gown with the blanket pulled up to his waist. The surveyor tried to engage Resident 89 in conversation, but Resident 89 made no eye contact nor spoke to the surveyor. Resident 89 was positioned in his bed, so he faced the wall to his right. Resident 89 was awake, staring at the wall and had his right two fore fingers in his mouth which he was aggressively chewing on and making vocalizations as he chewed. CNA 2 and CNA 3 stated the finger chewing had been an ongoing issue. They had attempted to give Resident 89 toys to hold and chew on, but Resident 89 would almost immediately drop the toy and forget about it. CNA 2 and CNA 3 explained that Resident 89 did not know to search for the toy once he had dropped it, so this approach had not been successful. CNA 2 stated he had asked the Licensed Vocational Nurse (LVN) charge nurse for mittens, but nothing came of it. CNA 3 assisted in visualizing Resident 89's fingers, it was observed that the fingernails on the left hand's thumb and first three fingers were severely affected. They were misshapen and deformed, exhibiting significant yellow discoloration, thickening, brittleness, and a crumbly texture. Furthermore, some of the affected fingernails had separated from the underlying nail bed. CNA 3 stated Resident 89 had chewed his left hand fingers a lot and had just started chewing on his right hand. Resident 89's right two fore fingers' nails and skin still looked healthy.During an observation and interview with the Interim Director of Nursing (IDON) on December 4, 2025, from 9:33 AM to 10:01 AM, the IDON stated she was not aware Resident 89's finger chewing had escalated to this point. The IDON stated there was no assessment on the fingernails on the Resident 89's left hand, This should have been picked up on the skin assessments and brought to the attention of the physician and then the wound nurse and it was not. The IDON stated when the CNAs did not get a response from the charge nurse they should have gone up the chain to the Registered Nurse (RN) supervisor and not waited this long to tell her on Monday December 1, 2025, that Resident 89 had a problem. The IDON stated there was no care plan to address this issue. After examining Resident 89's left hand fingernails, the IDON stated, This didn't happen overnight. The IDON stated Resident 89's finger-chewing behavior and nail deterioration should have been assessed and included in a care plan but were not.A review of the facility's policy and procedure (P&P) titled, Care Planning, dated January 25, 2025, indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 8. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 9. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents ' conditions change. 10. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS [Minimum Data Set] assessment as needed.

Based on observation, interview, and record review, the facility failed to ensure controlled substances (a drug or medication whose use is strictly regulated by the government due to its high potential for abuse) were reconciled accurately and in accordance with facility's policy and procedure (P&P), when a licensed nurse signed the facility's narcotics reconciliation log prior to completing the required physical count of the controlled substances.This failure had the potential to result in inaccurate accountability of controlled medications, delayed identification of discrepancies, and risk for medication diversion (the unauthorized use of a medication by someone other than whom it was prescribed for).Findings:During an observation on December 3, 2025, at 7:12 AM, the narcotic reconciliation log titled, Controlled Drugs - Count Record (narcotic reconciliation log for the medication cart in the 400 hall), dated December 2025, the log was signed by the PM shift nurse (Licensed Vocational Nurse 1 [LVN 1]) for the 7am - 7pm shift but the AM shift nurse (LVN 2) had not yet signed the log and the physical count of the narcotics had not yet been performed by LVN 1 or LVN 2.During an interview on December 3, 2025, at 7:16 AM, with the Director of Nursing (DON), the DON stated nurses were supposed to sign the controlled drug reconciliation record after physically counting the controlled drugs and after verifying the count of the medications.During an interview on December 3, 2025, at 7:27 AM, with LVN 2, LVN 2 stated the normal process for reconciliation of controlled medications was that the AM and PM nurses (the nurse coming off shift and the nurse coming on shift) count the physical medications and then sign the reconciliation log after the count is verified. LVN 2 further stated the controlled substances log dated December 3, 2025, 7am-7pm shift was already signed by LVN 1 (PM nurse) but the physical counting of the medications had not yet been done. LVN 2 stated the counting of the controlled substances was supposed to be done concurrently (at the same time) with both the PM nurse (LVN 1), and AM nurse (LVN 2).During an interview on December 3, 2025, at 7:38 AM, with LVN 1, LVN 1 stated she signed the controlled substances reconciliation log titled, Controlled Drugs - Count Record, dated December 2025, for the med cart in the 400 hall, prior to performing the physical count of the controlled substances. LVN 1 further stated the facility policy was that the PM nurse and the AM nurse were supposed to count the controlled substances together first, then both nurses would sign the log. LVN 1 again acknowledged that she had signed the reconciliation log prior to physically counting the medications.During concurrent interview and record review on December 3, 2025, at 8:04 AM, with the DON, the facility's policy and procedure (P&P) titled, Narcotic Count, dated January 2025, was reviewed. The P&P indicated, It is the policy of this facility to justify amount of narcotics remaining when control of supply is released to nurse coming on duty.1. One RN [registered nurse] or one LVN/LPN [licensed vocational nurse/licensed practical nurse] going off duty and one RN or one LVN/LPN coming on duty must count and justify narcotics supply for each individual resident at the change of each shift. 2. After the supply is counted and justified, each nurse must record the date and his/her signature verifying that the count is correct. The DON stated the policy and procedure was not followed by staff.

Based on observation, interview, and record review, the facility failed to ensure Resident 3's antibiotic medication (medication used to treat an infection) was labeled appropriately per facility's policy and procedure (P&P).This failure had the potential to result in administration errors, including administration of the wrong medication, wrong dose, wrong resident, or administration outside the ordered timeframe, thereby affecting Resident 3's safety.Findings:A review of Resident 3's admission Record (contains medical and demographic information), indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included heart failure, methicillin resistant staphylococcus aureus infection (an infection caused by an antibiotic-resistant bacteria), diabetes mellitus type 2 (a metabolic disorder characterized by persistent high blood sugar levels), and cellulitis of the left and right lower limbs (a bacterial infection of the skins deeper layers and underlying tissues).During a concurrent observation and interview on December 1, 2025, at 11:04 AM, with the Director of Nursing (DON), in Resident 3's room, Resident 3 was lying in bed and had an intravenous (IV - medication administered into the veins) bag of vancomycin (antibiotic medication) which had already been administered and was hanging at his bedside. The vancomycin antibiotic had no pharmacy label on it and had a label attached to it which indicated medication added, with the residents last name, room number, date, and time indicated on it. The medication added, label was left blank where it indicated, drug, amount, added by, rate, and base sol'n [solution]. The DON stated the IV antibiotic was not labeled correctly and only had the patient's last name, date and time of administration, and room number indicated on it.During a follow up interview on December 1, 2025, at 11:11 AM, with the DON, the DON stated the nurse who administered the vancomycin IV antibiotic was supposed to remove the pharmacy label from the foil pouch the vancomycin came in and apply it to the vancomycin bag once removed from the pouch, but it was not done.During an interview on December 3, 2025, at 11:50 AM, with the Consultant Pharmacist (CP), the CP stated IV vancomycin comes in a foil pouch which has a patient specific label affixed to the outside of the foil pouch. The CP further stated when the medication bag is removed from the foil pouch for administration to the patient, staff was supposed to remove the patient specific pharmacy label on the foil pouch and apply it to the medication bag.During a review of the facility's policy and procedure (P&P) titled, Medication Administration - Intravenous (IV) Administration of Drugs via Central Venous Catheters (CVC) or Peripherally Inserted Central Catheters (PICC), dated January 2025, the P&P indicated, .8. IV medications must be labeled in accordance with established procedures governing all labeling IV medications and IV solutions.During a review of the facility's P&P titled, Labeling and Storage of Drugs, revised January 2025, the P&P indicated, It is the policy of this facility that medications and biologicals are labeled in accordance with facility requirements, state and federal laws.1. Each prescription medication label includes: resident's name, specific directions for use, including route of administration, strength of medication. Injectables: strength per ml (cc) and the amount to be given in mls [milliliters - unit of measure] equivalent on label, physician's name, date medication is dispensed, quantity, expiration date, name, address, and telephone number of provider pharmacy, prescription number, accessory label indicating storage requirements and special procedures. Example: shake well; Take on empty stomach.container number and total number of containers.when multiple containers are dispensed for one prescription.

Based on interview, and record review, the facility failed to protect against physical abuse for one of three sampled female residents (Resident 1) when a male resident (Resident 2) kissed Resident 1 on the mouth and fondled her (to touch in a sexual way) when Resident 1 did not have the capacity to consent. This failure had the potential to cause Resident 1 to suffer psychological distress, anxiety, and shock. Findings: An unannounced visit was made to the facility on [DATE], at 10:45 AM, to investigate a facility reported incident regarding an allegation of physical abuse. A review of Resident 1 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an admitted [DATE]. Resident 1 had diagnoses that included dementia (a brain disorder that causes a decline in mental abilities, such as memory, thinking, reasoning, and problem-solving) and quadriplegia (a condition characterized by the loss or severe impairment of motor function, sensation, and nervous system functions in all four limbs--arms and legs). A review of Resident 1 ' s physician ' s history and physical (H&P-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), dated March 30, 2024, indicated, Patient Informed of Medical Condition: No, Patient Capable of Admitting Self: No, Patient Capable of Making Decisions: No. During an interview with Resident 2 on January 29, 2025, at 11:41 AM, Resident 2 stated he kissed Resident 1 on the mouth and put his hands on Resident 1 ' s breasts. Resident 2 stated Resident 1 had asked him to stop, so he stopped and that was when the nurse told him to step away from Resident 1, so I walked away. During an interview with Resident 1 on January 29, 2025, at 12 PM, Resident 1 stated she had called Resident 2 over as he passed in the hallway and kissed him. Resident 1 stated Resident 2 was receptive to her advance and began touching her breast. Resident 1 stated she told Resident 2 that was a far as he could go, and Resident 2 stopped. Resident 1 stated that was when the nurse came and told Resident 2 move away from her. Resident 1 stated she had wanted the sexual contact and Resident 2 had been receptive to her. During an interview with a Certified Nursing Assistant (CNA 1) on January 29, 2025, at 12:30 PM, CNA 1 stated she was standing at the nursing station, the 400 hallway was behind her, and as she turned around, she saw Resident 2 leaning over Resident 1 with his hand down inside her shirt. CNA 1 stated Resident 1 was in her Geri chair (large, padded chair with a wheeled base) positioned in the hallway and Resident 2 was leaning over her and she said to Resident 2 to step away, back away from Resident 1. CNA 1 stated Resident 1 and Resident 2 looked up at her with shocked expressions and did not say anything and Resident 2 began walking down the hallway away from Resident 1. CNA 1 stated she stood next to Resident 1 to provide protection and flagged down another staff person to get the Charge Nurse for the 400 hallway, the Charge Nurse came, and she gave report of the situation. CNA 1 stated Resident 1 seemed to laugh it off as the Charge Nurse asked her questions about what had happened, and Resident 1 did not appear to be upset by the situation. During an interview with the Director of Nursing (DON) on January 29, 2025, at 1:43 PM, the DON stated Resident 1 did not have the capacity to consent to sexual contact and sexual contact had occurred between Resident 1 and Resident 2. The DON stated the facility had not protected Resident 1 from physical abuse. A review of the facility ' s policy and procedure (P&P) titled, Resident Rights, dated December 2021, indicated, Policy Interpretation and Implementation:1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation .

Based on interview, record review, and facility policy review, the facility failed to ensure the preadmission screening and resident review (PASRR) was accurately completed for 1 (Resident #44) of 3 sampled residents reviewed for PASRR requirements. Specifically, Resident #44 had a serious mental illness (SMI) that was not captured in their Level I PASRR screening. Findings included: A facility policy titled, PASRR Completion Policy, reviewed 12/2023, specified, The Center will a [sic] make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. The policy specified, 1. Center Administrator will designate the medical records to make sure that the [PASRR]and/or Level of Care (LOC) is done on all potential residents. If the referral indicates anything which might constitute an SMI or ID [intellectual disability], the PASRR must be completed prior to admission. An Admission Record revealed the facility admitted Resident #44 on 08/02/2024. According to the Admission Record, the resident had a medical history that that included diagnoses of bipolar disorder (onset 08/02/2024) and anxiety disorder (onset 08/02/2024). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/2024, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #44 had active diagnoses to include anxiety disorder and of manic depression (bipolar disease). Resident #44's care plan included a focus area initiated 08/05/2024, that indicated that the resident had a mood problem related to bipolar disorder and anxiety disorder. Interventions directed staff to refer the resident for behavioral health consultations as needed. Resident #44's physician orders revealed an order dated 08/04/2024, for quetiapine fumarate (an antipsychotic) oral tablet 24 milligrams, one tablet by mouth at bedtime for bipolar manifested by mood swings. Resident #44's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 08/02/2024, indicated that the resident had no diagnosed SMIs and did not have a suspected mental illness. During an interview on 11/13/2024 at 3:35 PM, the Social Services Director stated that the hospital completed the resident's Level I PASRR screening. She stated that she was not sure what the process was for the facility staff to review Level I PASRR screenings for accuracy or who was responsible for reviewing them. During an interview on 11/13/2024 at 3:57 PM, the Medical Records Resource stated that the hospital created Resident #44's Level I PASRR screening. She stated that she did not know of any process to review hospital Level I PASRR screenings for accuracy or who was responsible for reviewing them. During an interview on 11/13/2024 at 12:57 PM, the Director of Nursing stated that he was not sure if there was anyone in the facility who reviewed Level I PASRR screenings from the hospital for accuracy, but he believed that it was the responsibility of medical records staff. During an interview on 11/13/2024 at 1:13 PM, the Administrator stated that medical records staff were responsible for PASRR accuracy.

Based on interview, record review, and facility policy review, the facility failed to ensure staff administered medication as ordered for 1 (Resident #16) of 5 sampled residents reviewed for unnecessary medications. Findings included: An undated facility policy titled, Medication Administration - General Guidelines specified, Medications are administered in accordance with written orders of the attending physician. An Admission Record revealed the facility admitted Resident #16 on 01/28/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of hypertensive heart disease with heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/16/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #16's Order Summary Report, for active orders as of 11/13/2024, revealed an order dated 01/28/2024, for bumetanide oral tablet 2 milligrams, give one tablet by mouth one time a day for congestive heart failure, hold for systolic blood pressure (SBP) less than 110 millimeters of mercury (mmHg). Resident #16's medication administration record (MAR) for the timeframe from 10/01/2024 through 10/31/2024, revealed evidence to indicate Licensed Vocational Nurse (LVN) #2 administered bumetanide 2 mg to the resident when the resident had a SBP of 102 mmHg on 10/02/2024. During an interview on 11/13/2024 at 1:37 PM, LVN #2 stated that staff were supposed to check that the resident's blood pressure was within parameters before administering medication. She stated that Resident #16's MAR indicated the resident received their bumetanide when the resident's blood pressure was outside of the physician-ordered parameters. She stated that she had been a nurse long enough to know not to do that. During an interview on 11/13/2024 at 3:10 PM, Medical Doctor #10 stated staff should have followed the parameters set by the physician with regards to medication administration. During an interview on 11/14/2024 at 12:57 PM, the Director of Nursing (DON) stated that nurses should follow the physician-ordered parameters with regards to medication administration. During an interview on 11/14/2024 at 1:13 PM, the Administrator referred to the DON regarding medication administration and physician-ordered parameters.

Based on observation, interview, record review, and facility policy review, the facility failed to provide facial grooming for 1 (Resident #76) of 2 sampled residents reviewed for activity of daily living (ADL) care. Findings included: A facility policy titled, ADL, Services to carry out, reviewed 12/2023, revealed, It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities. The policy revealed, 2. Residents who are unable to carry out activities of daily living (ADL) will receive necessary services to maintain, including Grooming. An Admission Record indicated the facility admitted Resident #76 on 09/26/2024. According to the Admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis (muscle weakness and paralysis on one side of the body) following a cerebral infarction (a stroke) and complete traumatic trans metacarpal amputation of left hand. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/13/2024, revealed Resident #76 had moderate impairment in cognitive skills for daily decision making and had short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS). The MDS indicated the resident did not exhibit any behavior of rejecting care during the assessment timeframe. Per the MDS, the resident was totally dependent on staff for personal hygiene needs. Resident #76's care plan included a focus area initiated 08/20/2024, that indicated the resident had an ADL self-care performance deficit. The care plan indicated that the resident was totally dependent on staff for personal hygiene. Resident #76's Skin Monitoring: Comprehensive CNA [certified nurse aide] Shower Review, dated 11/08/2024 and completed by CNA #9, indicated the resident had a bed bath. T During an interview and observation on 11/11/2024 at 9:45 AM, Resident #76 was observed with facial hair on their chin, cheeks, and upper lip approximately 1/4 inch long. When asked if they liked having facial hair, Resident #76 shook their head, indicating that they did not. During an interview on 11/12/2024 at 10:16 AM, Resident #76's family member stated the staff shaved the resident about once a month. On 11/13/2024 at 1:43 PM, CNA #9 stated that it was her first time to work with Resident #76 on 11/08/2024. She stated that she did not know if the resident preferred to be shaved or not. She stated she did not shave Resident #76 on 11/08/2024 during the resident's bed bath. On 11/14/2024 at 7:54 AM, Licensed Vocational Nurse #7 stated that staff should know the preferences of the residents, and if they did not know, they should ask. She stated Resident #76 liked to be clean shaved. On 11/14/2024 at 8:32 AM, the Director of Nursing stated that whatever the resident could not do, the staff should do for them. He stated that staff should wash the residents' hair and offer to shave. On 11/14/2024 at 10:53 AM, the Administrator stated that staff should assist the resident with bathing. She stated the staff should offer to shave the resident during that time. She stated that the staff should know the residents' preferences.

Based on interview, record review, and facility policy review, the facility failed to transcribe a physician order from an outside ear, nose, and throat (ENT) physician for 1 (Resident #70) of 1 resident reviewed for communication sensory concerns. Findings included: A facility policy titled, Physicians, Consulting, revised 12/2023, revealed, Purpose To promote continuity of care. The policy revealed, 5. If treatment or medications are ordered by the consulting physician, it will be communicated to a licensed staff to carry out the new treatment order. 6. Medication/treatment will be transferred to MAR [medication administration record]/TAR [treatment administration record], ordered from pharmacy/other, and treatment or medication regime initiated, and family and/or resident informed of change in plan of care. An Admission Record indicated the facility admitted Resident #70 on 02/07/2024. According to the Admission Record, the resident had a medical history that included diagnoses of intraspinal abscess and granuloma and muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/01/2024, revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. A physician note, dated 10/02/2024, revealed Resident #70 was seen by a physician assistant for diminished hearing, nasal congestion, throat congestion/clearing, and stuffy ears. According to the physician note, the plan included use an earwax removal aid drops twice a day for four days in the resident's left ear. Resident #70's MAR for the timeframe from 10/01/2024 through 10/31/2024 revealed no evidence of an order that directed staff to instill drops in the resident's left ear. On 11/11/2024 at 11:13 AM, Resident #70 stated they were seen by an ENT physician a month ago and the facility did not administer the ear drops as ordered. On 11/13/2024 at 7:52 AM, the Social Services Director (SSD) stated the ENT physicians came in every nine weeks. She stated the physicians were able to write orders. She stated that the orders were given to the nurse and the nurse placed (transcribed) the orders into the computer. On 11/13/2024 at 9:51 AM, Registered Nurse (RN) #6 stated that orders were given to the charge nurse on the hall or the desk nurse. She stated that nursing staff were supposed to follow up on the orders. She stated that the RN supervisor should be following up as well to ensure the orders were completed. RN #6 reviewed Resident #70's medical record and stated that the order was not carried out. She stated that the order should have been carried out and stated that there was a delay of care. On 11/13/2024 at 10:53 AM, Licensed Vocational Nurse (LVN) #7 stated that when the physician completed their rounds, the physician found a floor nurse to give the orders to. She stated that from there, the orders were carried out and put (transcribed) into the medical system. She stated that she remembered the physician giving her the orders for the day, but not sure if there were any orders for Resident #70. She stated she did not recall transcribing an order for Resident #70. LVN #7 stated that the orders should be put in that same day and if not, they could pass it on to night shift. She reviewed resident #70's medical record and the order summary for October 2024 and November 2024 and stated that she must have just not transcribed the order in the computer. On 11/13/2024 at 3:25 PM, the Director of Nursing (DON) stated that the staff should work with the ancillary physician and follow through with what the physicians asked of the facility. On 11/13/2024 at 3:32 PM, the Administrator stated that she expected the nursing department to follow up with the order to clarify if needed, and to carry out the order. She stated that she expected the order to be put in the day the order was received or the following day. She stated that the order from the ENT was not carried out. On 11/14/2024 at 1:51 PM, the DON stated the facility was unable to produce the physician orders that were given to the nurse on duty.

Based on observation, interview and record review, the facility failed to implement a care plan (a document outlining how to best care for a resident and meet their needs) for one of three sampled residents (Resident 3) after Resident 3 suffered a fall with injury. This failure had the potential for Resident 3 to suffer a subsequent fall that could result in another injury or worsening of Resident 3's current injury to his left ribs. Findings: During a review of Resident 3's Admission Record (a document with basic client information), the Admission Record indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD - a disease of the lungs that causes air-flow blockage and breathing-related problems), Epilepsy (abnormal electrical brain activity, also known as a seizure) and History of Falling (resident has fallen in the past). During an observation on February 8, 2024 at 9:48 AM, in the facilities 400 hallway, Resident's 3 room was located at the end of the 400 hallway and not close to the nurses station. During a concurrent observation and interview on February 8, 2024, at 9:52 AM Resident 3's room with Certified Nursing Assistant (CNA 1) Resident 3's call light (device used to call for help and assistance) was tied to the bed rail and hanging near the floor behind his head and not accessible to Resident 3. CNA 1 stated Resident 3 could not reach the call light and Resident 3 could decide to get up to call for help and fall again. During a concurrent interview and record review on February 8, 2024, at 11:00 AM with Licensed Vocational Nurse (LVN 1), Resident 3's Care Plan dated January 31, 2024 was reviewed. The Care Plan indicated, .Interventions Attach call light to bed within access of resident .Place resident close to nursing station for close observation . LVN 1 stated Resident 3's care plan was not fully implemented . She stated Resident 3's room is not close to the nurse's station and the resident should be able to access his call light from his bed. The LVN 1 further stated, Resident 3 would have difficulty requesting help if he needed it and could try to get up and fall again. During a concurrent interview and record review, on February 8, 2024, at 11:30 AM, with Registered Nurse (RN), the facility policy and procedure (P&P) titled, Care Planning, undated, was reviewed. The P&P indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .1. The interdisciplinary Team (IDT) .develops and implements a comprehensive, person center care plan for each resident . RN stated, the purpose of a care plan is to implement interventions to prevent another fall. RN further stated Resident 3 could have fallen again if he was not able to reach the call light and him being far away from the nurses station makes it hard for staff to observe Resident 3 and monitor him for falls. During a review of the facility's policy and procedure (P&P) titled, Falls-Clinical Policy, undated, the P&P indicated, .Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls .

Based on observation, interview, and record review, the facility failed to ensure the psychosocial wellbeing of 1 out of 3 residents (Resident 1) when the facility put a screw on the window in Resident 1's room to prevent widow from opening all the way. This failure placed resident 1 at risk of depression, and a decline in psychosocial harm when Resident 1 stated he does not feel safe with screw is in the window. Findings: An unannounced visit was made to the facility on [DATE], at 10:25 AM to investigate a complaint regarding Quality of Care/Treatment and Physical Environment. During a review of resident 1 ' s Admission Record (general demographics), the document indicated resident 1 was admitted to the facility on [DATE], with a diagnosis to include Muscle weakness, other lack of coordination, low back pain, Encephalopathy (a group of conditions that cause brain dysfunction). During an interview with Resident 1, on December 27, 2023, at 10:45 AM, he stated he is doing well and is just concerned about the window. He states what happens if there is a fire? We could all get killed, there is no way to get out if the door or the hallway is on fire, and they cannot get to us, I do not feel safe with screw on window. During an interview with Administrator (AD) on December 27, 2023, at 10:30 AM, he stated to maintain temperature regulation for the facility all windows are secured and have a lock. There are other escape routes. He states all resident windows are secure with a screw. He stated he is not sure if it ' s in [NAME] 22 but he will have the Building director talk with me. During an interview with Building and Facilities director on December 27, 2023, at 10:35 AM, he stated that when he spoke with Life and Safety, he was told that all windows can be secured, even with a screw, to not disrupt air balance. He let me know he reached out to Life and safety to email him the policy where it states it is ok to secure windows in that manner. During an interview with DON (Director of Nursing) on December 27, 2023, at 11:00 AM, she stated she is aware all windows are secured with a screw and in case of a fire there are escape routes throughout facility. States she is not sure why there are screws om windows. During an interview with maintenance on December 27, 2023, at 12:21 PM, he stated he is aware the windows are shut with a screw, states yes I am aware they are states we have a problem maintain the right temperature during the summertime because some residents open the windows. When asked should they be shut with a screw? He states it keeps the residents from opening the windows and disrupting the air balance.

Based on interview, observation and record review, the facility failed to remove a building hazard, a threshold (a strip of wood, metal, or stone forming the bottom of a doorway and crossed in entering a house or room) that leads to the patio and is used by residents and families creating a hazard which poses a risk for falls. This failure placed two out of three residents (Resident's 1 and 2) at risk for severe injuries due to falls. Findings: An unannounced visit was made to the facility on [DATE], at 1:19 PM, to investigate a complaint regarding quality of care and Accidents. During review of resident 1's Admission Record (general demographics), the document indicated resident 1 was admitted to the facility August 1, 2023, with diagnosis to include Muscle weakness, Hemiplegia(paralysis on one part of the body) and Hemiparesis (weakness or the inability to move on one side of the body) affecting right dominant side following Cerebral Infarction(a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). During a review of resident 1's progress note, (An ongoing record of a patient's illness and treatment) dated November 19, 2023, at 7:05 AM, the document by Licensed Vocational nurse (LVN 1), it indicated, Another resident was yelling for help. I went to the patio resident was lying on her right side, her right leg was wrapped around the wheelchair that was behind her, she was fully clothed. This happened in the patio entrance into the facility. Resident stated she was trying to get back into the facility and when she reached the doorknob she fell out of her chair, she has a hematoma (a localized swelling that is filled with blood caused by a break in the wall of a blood vessel(a network of tubes through which blood is pumped around the body) on her right forehead with 8/10 pain, res on observation could move all extremities, had PERLA (an acronym for pupils are equal, round and reactive to light and accommodation. Healthcare providers use the PERRLA eye test to check if your pupils look and function as they should), hand grasps bilat weak. She was lifted off floor via 2 persons assist and placed back into her wheelchair. Doctor was notified and res was sent to the ER (emergency room ) for further eval. BP (blood pressure, the pressure of blood pushing against the walls of your arteries) 183/78, r (respiratory)85, O2 Sat (measures the percentage of oxyhemoglobin (oxygen-bound hemoglobin) in the blood) 96, temp (temperature) 97.5. During an interview with resident 1, she stated I fell trying to go to the patio, that thing on the floor to the patio is hard to get over it . She sated she hit her face and her leg has bruises (skin discoloration from damaged, leaking blood vessels underneath your skin). During review of resident 2's Admission Record, the document indicated resident 2 was admitted to the facility March 5, 2019, with a diagnosis to include acquired absence of right leg below knee, Hemiplegia and Hemiparesis affecting right dominant side. During a review of resident 2's progress note dated November 26, 2023, at 9:27 PM, the document by LVN 2, it indicated, resident had unwitnessed fall at 2020 hours. It appears that resident was attempting to come back in the facility from smoking and his w/c (wheelchair) tipped backward. Resident hit the back of his head on the concrete. Sent resident to ER. Resident had 2 seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), while awaiting paramedics. First seizure lasted 20 seconds. Second seizure lasted 40 seconds. Paramedics arrived and transported resident to hospital at 2100 . During an interview with resident 2, he stated he is fine and has no issues. States he does not have issues with his wheelchair. States yeah I fell but does not remember when or how. We were by the door, and he wheeled himself through the door without difficulty. During an interview with RN 1 (registered nurse) on November 27, 2023, at 1:40 PM, she stated she is aware of the door threshold by the patio. States she has told maintenance to take care of it but they haven't sates overall everything in the facility is good . During an interview with [NAME] AD (administrator) on November 27, 2023, he stated He stated the threshold was installed a couple of months ago. He stated that they had an IDT (interdisciplinary team) meeting today regarding the threshold on the patio door. It was decided that it will be taken out . On the same day [NAME] notified me at 2:20 PM the threshold to the patio has been taken out . Visually verified. During record review on November 27, 2023, at 2:50, review of Policy and Procedures Titled Falls and Fall Risk, Managing dated March 2018, the document indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . It also indicates , 1. Environmental factors that contribute to the risk of falls includes: d) obstacles in the footpath.

Based on interview and record review, the facility failed to ensure a request for documents was fulfilled in a timely manner for two of three sampled residents (Resident 1 and Resident 2) when the facility did not provide the requested documents within the timeframes specified in their policies. This failure had the potential to result in the Resident ' s denial of a timely due process. Findings: An unannounced visit was made to the facility on [DATE], at 11:00 AM, to investigate a complaint regarding quality of care. During a review of the Medical Records Requests: 1. Resident 1 had a letter sent to the facility by [name of legal firm] which indicated the facility received a request for release of Resident 2 ' s medical records on October 24, 2023. Review of the confirmation fax document (states when the document was sent to the legal firm) indicated the medical records for Resident 1 was sent on November 14, 2023 (sixteen days after they received the typewritten documents request) to the [name of legal firm.] 2. Resident 2 had a letter sent to the facility by [family member] which indicated the facility received a request for release of Resident 2 ' s medical records on October 23, 2023. There was documented evidence that the medical records were released and sent to the [family member] on October 27, 2023. During an interview with the Medical Records representative (MR) on November 15, 2023, at 11:15 AM, MR indicated she received the medical records request but had been advised by Corporate office (CO) that all medical records request are to be sent to their office for approval and she waited for confirmation from CO to release the medical records. MR stated she was aware that per [NAME] 22 she was to release medical records within 2 business days. During an interview with the Administrator (AD), on November 16, 2023, at 9:00 AM, he stated they do send medical records request to CO and that he will check and make sure medical records for [name of legal firm] were released. A review of The Facility Policy and Procedure titled Release of Information, Minimum Necessary Use undated, indicated Subpoena and/or court orders will be processed in accordance with the current state law and facility policy.

F642 Based on interview and record review, the facility failed to ensure proper security measures were in place to protect the use of an electronic signature. When (Licensed Vocational Nurse LVN1) used (Registered Nurse RN 1), electronic signature to sign a (Minimum Data Set MDS) verifying the MDS is complete for 66 residents. This failure had the potential to cause inaccuracies in the completed comprehensive assessment in the MDS's for 66 clinically compromise residents. During an interview on October 4, 2023, at 11:22 AM, with the Activities Director, (Activities Director focuses on creating activities that enrich participants' lives with physical and cognitive exercise and socialization through recreational activities such as sports, dancing, arts, and crafts). The Activities Director stated she assesses residents by filling out the Minimum Data Set Assessment (MDS- a computerized resident assessment instrument) States she goes to the residents' room and uses a paper form, then goes on PCC (PointClickCare, a cloud-based healthcare Software provider) to document and keeps paper form in a binder in her office. She then signs off with her password. She stated if her password does not work, she will talk to DSD (Director of Staff Development) or administrator to reset her password. She also stated she had an in-service and signed a paper that state no sharing of password. During an interview on October 4, 2023, at 1131 AM, with DSD Assistant, she stated she does the supplemented training. She stated she did the training because some passwords were not being protected, that there were issues with information that needs to be shared with other and things were being signed off . Stated that if her password is not working, she would contact information support at Corporate Office through email. States staff usually go to nursing supervisor or administration. During an interview on October 4, 2023, at 1145 AM, with Dietary Supervisor, she stated her MDS documentation part is the letter K, Swallowing and Nutritional status. Stated she does the assessment in the residents' room, once the assessment is done and completed, she documents on PCC, she then signs at the end using her passcode. States if her passcode does not work, she will let administration know. She stated she knows not to share her passcode because that is her signature, and it was told to her on orientation by staff development. During an interview on October 4, 2023, at 1200 PM, with MDS nurse, she stated, her passcode needed to be reset and she asked Medical Records Director, who created a new profile instead of resetting password. States she does her resident assessments in the rooms then goes to the office and enters data and signs assessment she did. States then the DON (director of nursing) signs for the RN (registered nurse). States he makes sure her sections are completed. During an interview on October 4, 2023, at 1215 PM, with DON, she stated she has not done MDS as an MDS nurse. States she understands there were 66 modifications during September 6, 2023, through September 12, 2023, to make a correction or an adjustment. States that if her passcode was used, she would report to administration that someone used her passcode. She stated she has been employed for a year and in orientation they talked to her about not sharing her passcode. During a concurrent interview on October 4, 2023, at 12:52 PM, with Administrator and DON, the administrator stated his knowledge base of the MDs is the same as a High-level Rehab Director (Director of Rehabilitation). States the Rehab Director puts in the minutes in the MDS, and the rehab Director makes sure the therapy department minutes are accurate before sending them over. States there are 66 modifications on MDS to make sure they are accurate and to make sure an accurate RN signature. Stated they were under the direction of RAI (Resident Assessment Instrument) to modify signatures. Stated before doing that they went to RAI or probably a third-party auditor. Stated the in-service of Policy and Procedure review on September 29, 2023, was to review MDS completion and Passwords and User ID codes. Stated he will have staff come in at all hours to ensure all staff are in serviced. During an interview on October 4, 2023, at 1:00 PM, with a ADON (Acting Director of Nursing), he stated he has been employed for 3 months. Stated he was ADON from July 5, 2023, through September 24, 2023. He stated that while he was acting ADON, he did not do anything with MDS because he probably got 1.5 hours of training. Stated his understanding of signing off the MDS is to make sure MDS is complete since this investigation started. Stated they told him he was signing that each section was completed. His understanding of how his signature got on the MDs was when he raised the flag that his password was being reset. He stated that his password was reset 2 weeks into him being ADON and in July his password was reset a few times. States that in August while he was on vacation his password was also reset a few times. States that it was brought this attention by the medical records that there was 112 pages of documentation with his signature. He states his understanding if his password does not work, he would notify medical records then she would reach out to Corporate office resources, and they would reset it. He stated that he believes it was Medical Records Director. He stated that if he was not able to log on to PCC and would get a notification to reset, it was reset to a default and that way LVN 1 MDS resource, was able to sign off all the MDS under his name. During a review of the facility's Policy and Procedure titled Electronic Signatures and Electronic Orders revised April 2021, the policy and procedure indicated the HCP will receive an individual identifier access code from an appropriate administrative person. The access code is for his/her use only.

Based on observation, interview, and record review, the facility failed to provide a safe environment free from abuse and neglect for one of 88 residents (Resident 1) when a Licensed Vocational Nurse 1 (LVN 1) failed to do the following for a resident who had just returned from the general acute care hospital for a complaint of chest pain: 1. Failed to assess Resident 1 upon readmission from the emergency room for pain and to take vital signs (temperature, pulse, respirations and blood pressure). 2. Failed to medicate Resident 1 for repeated episodes of nausea and vomiting for several hours as per physician's orders [REDACTED]. 3. Failed to notify Resident 1's physician that Resident 1 had returned from the emergency room with vomiting, severe abdominal pain, high blood glucose level and the prescribed insulin coverage had not been given. These failures resulted in Resident 1 suffering unnecessary pain, having a rapid decline in her health which ended in her death within eight hours of returning to the facility. Findings: 1. A review of Resident 1's clinical record, the face sheet (Contains demographic information), indicated Resident 1 was admitted to the facility on [DATE], and died in the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's history and physical dated [DATE], indicated Resident 1 was deaf (impaired hearing or unable to hear) and had an arteriovenous fistula (AV shunt, a surgically created connection between an artery (a blood vessel that carries blood away from the heart to the rest of the body) in left upper arm (LUE). Resident 1 was alert and capable of making decisions. During a review of Resident 1's Nurses Progress Notes indicated the following: a. [DATE] at 2:10 PM, Resident 1 has not returned from the [MEDICAL TREATMENT] center. Charge Nurse/Registered Nurse Supervisor (CN/RNS) called the center and informed Resident 1 complained of (C/O) chest pain and (was)transported to the hospital. b. [DATE] at 6:54 AM, Resident 1 returned from emergency room (ER) on [DATE] at 11:20 PM, in a wheelchair (W/C) accompanied by one attendant. All labs came back within normal limits (WNL). Resident 1 was treated for [REDACTED]. [MEDICATION NAME] (medication for nausea and vomiting) given x1. No medications taken by Patient. Will continue to monitor. There was no documented assessment of Resident 1's vital signs, or level of pain upon return from the general acute care hospital. A review of Resident 1's, Weights and Vitals (vital signs) Summary, dated [DATE] through [DATE], indicated that no vital signs had been documented after [DATE], at 5:21 AM, when Resident 1 left for [MEDICAL TREATMENT]. During an interview with the Director of Nurses (DON), on [DATE], at 12:25 PM, the DON confirmed Resident 1 had no assessment or V/S completed after returning from the hospital on [DATE] at 11:20 PM. The DON stated, Resident 1 should have been placed on 72- hour charting when returning from the hospital with chest pain and the physician should have been notified. During a telephone interview with LVN 1 on [DATE], at 2:30 PM, LVN 1 confirmed, Resident 1 returned from (Name of Hospital) on [DATE] at 11:20 PM, after being evaluated in the emergency for complaint of chest pain. LVN 1 stated she did not complete an assessment or take V/S when Resident 1 returned. When asked the reason an assessment of Resident 1 and vital signs was not completed upon return from the emergency room , LVN 1 stated, I was too busy to complete an assessment and take V/S and then ran out of time. 2. During further review of Resident 1's Nurses Progress Notes the notes indicated the following: a. [DATE] at 9:07 AM, Resident 1 was administered [MEDICATION NAME] (medication to treat diarrhea) A-D Tablet 2 Milligrams (MG-unit of measure) twice for diarrhea. b. [DATE] at 4:32 PM, Resident 1 did not go to [MEDICAL TREATMENT] due to her stomachache. Informed a new chair time (reservation at the [MEDICAL TREATMENT] center) was arranged for tomorrow at 8:00 AM. Social Services Worker (SSW) will continue to follow. RNS (Registered Nurse Supervisor) and CN (Charge Nurse) made aware. c. [DATE] at 8:36 PM, Resident 1 refused to go to [MEDICAL TREATMENT], different staff came to try and convince her to go, and still refused. Called [MEDICAL TREATMENT] and got her rescheduled for Tuesday at [DATE] at 8:00 AM. There was no documented evidence the physician had been notified that Resident 1 refused her [MEDICAL TREATMENT] due to abdominal pain and diarrhea. During a review of Resident 1's physician's orders [REDACTED]. a. [MEDICATION NAME] (medication given for pain or to reduce fevers) 1 Tablet 325 MG by mouth (PO) every (Q) 4 hours as needed for general discomfort. Order date [DATE]. b. [MEDICATION NAME] (Medication for nausea and vomiting) Tablet 4 MG- Give 1 tablet by PO Q 8 hours as needed for nausea and vomiting (N/V). Order date [DATE]. A review of Resident 1's Medication Administration Record [REDACTED] a. [MEDICATION NAME] Tablet 325 MG PO last administered on [DATE] at 10:05 AM. b. [MEDICATION NAME] 4 MG PO administered on [DATE] at 6:02 AM (Seven hours after Resident 1 returned from the ER and had started vomiting). Review of Resident 1's Nurses Progress Notes dated [DATE] at 6:02 AM, indicated Resident 1 given 1 tablet of [MEDICATION NAME] 4 MG PO Q 8 hours as needed for N/V. During an interview with the Social Service Worker (SSW) on [DATE] at 12:15 PM, the SSW stated she had been helping Resident 1 who had been complaining of a stomachache the last two days before she died . The SSW stated she had to reschedule Resident 1's [MEDICAL TREATMENT] appointment to [DATE]. The SSW further stated when speaking with Resident 1's room-mate, she expressed concerns about Resident 1's death and stated, Resident 1 yelled in pain and vomited all night. A review of Licensed Vocational Nurse 1 (LVN 1) statement provided to the Director of Staff Development (DSD) dated [DATE], indicated, During the evening of [DATE], while taking care of Resident 1, Resident 1 had vomited clear emesis and complained of a stomachache. My Certified Nurses Assistants (CNA) were instructed to clean up Resident 1 and the floor many times during the night. LVN 1 went into Resident 1's room to check on her and stated, Resident 1 was moaning loudly and continued to say she had a stomachache. During an interview with the Director of Nurses (DON), on [DATE], at 12:25 PM, the DON confirmed Resident 1 was not appropriately monitored after returning from the hospital. The DON stated, Resident 1 was not provided good care by LVN 1. The DON further stated, Resident 1 should have been administered medication in a timely manner for vomiting and offered medication for C/O abdominal pain. During a telephone interview with LVN 1 on [DATE], at 2:30 PM, LVN 1 confirmed Resident 1 returned from (Name of Hospital) on [DATE] at 11:20 PM, and had vomited multiple times before she had administered any anti-nausea medication and she had not offered any pain medication when Resident 1 had C/O pain several times that night. LVN 1 further stated, I was too busy, and I was sending my CNA's (certified nursing assistants) to check on her. During an interview with Resident 2, (Resident 1's room-mate), on [DATE], at 3:00 PM, Resident 2 confirmed Resident 1 came back from the hospital on [DATE] late in the evening, vomiting and C/O a stomachache. Resident 2 stated, Resident 1 was deaf, kept vomiting and cried all night long of a severe stomachache. When staff would come in, they would yell at both of us to be quiet. Resident 2 stated in the early morning, when Resident 1 had vomited, LVN 1 came in and said, We are too busy to clean you up. When staff left the room someone said, [***] . Resident 2 further stated, I knew when the room was quiet Resident 1 had passed away and I could not help her. 3. Review of Resident 1's Nurses Progress Notes dated [DATE] at 7:58 AM, indicated Resident 1 during morning medication pass was in bed rocking back and forth and had emesis x1. [MEDICATION NAME] 4 MG was given to Resident 1. Her 6:00 AM Blood Sugar (BS) was 397. No insulin was administered to Resident 1. Resident 1 was heard in every room yelling until around 6:50 AM. Change of shift the CNA stated she was not sure if Resident 1 was breathing. Oncoming nurse and this nurse ran down to Resident 1's room to check. Resident 1 was unresponsive. No pulse, or Blood Pressure (B/P), was found. Cardio-Pulmonary Resuscitation (CPR-emergency procedure that combines chest compressions with ventilation to manually preserve brain function) was started and 911 was called. Paramedics arrived, CPR was done for 20 minutes and they were unable to revive Resident 1. It was called a 7:38 AM (Resident 1 was pronounced dead). Resident 1's sister was notified at 8:00 AM. Review of Resident 1's physician's orders [REDACTED].-inject right under the skin) every day (QD). In addition, Resident 1 had an order to receive sliding scale insulin meaning orders for insulin are to be administered based on the results of Resident 1's finger stick blood sugars (BS) with [MEDICATION NAME] (medication used to control high BS) insulin- Flex-Pen Solution Pen-Injection 100 Units (U)/Milliliters (ML-unit of measure) inject per sliding scale ,[DATE]- no insulin. Before meals (AC) and at bed time (HS) as follows: a. Blood sugar ,[DATE]- give -8 U of insulin b. Blood sugar ,[DATE]- give 12 U of insulin c. Blood sugar ,[DATE]-give 15 U of insulin d. Blood sugar ,[DATE]-give 18 U of insulin e. Blood sugar ,[DATE]- give 20 U of insulin f. Blood sugar 400 or greater call MD A review of Resident 1's MAR indicated [REDACTED]. The BS documented on [DATE] at 6:00 AM was 397 and the prescribed dose of 20 units of [MEDICATION NAME]was not administered. There was no documentation to indicate the physician was notified it was not given nor that she had been vomiting all night. During a telephone interview with LVN 1 on [DATE], at 2:30 PM, LVN 1 confirmed, she did not notify Resident 1's physician during the night that she had been vomiting and had been yelling out in severe abdominal pain. LVN 1 stated she did not notify Resident 1's physician that her BS was 397 and withheld her insulin because she was vomiting. When LVN 1 was asked if the protocol would be to notify the physician when a resident has a change of condition (COC- significant change in the resident's physical/emotional/emotional/mental condition), LVN 1 stated, I should have called but, I was too busy. During an interview with Director of Staff Development (DSD), on [DATE], at 3:20 PM, the DSD stated LVN 1 should have initiated a, COC, placed on 72-hour charting, called Resident 1's physician and notified him regarding her vomiting, severe abdominal pain and her BS being 397. The DSD stated he is in- charge of training staff and provided no additional training for LVN 1 after an allegation for abuse was made by Resident 2 and no COC was completed for Resident 1 A review of LVN 1's employee file for training since hire date indicated she was hired on [DATE]. She had signed as having received the following trainings: a. Mandated Reporter (related to abuse and neglect)-dated [DATE] b. Staff Abuse Training/Elder Abuse-dated [DATE] c. Pre/Post Elder Abuse Test-dated [DATE] d. Resident Rights/Abuse Prevention- dated [MEDICAL CONDITION] A review of the disciplinary action form dated [DATE] for LVN 1 indicated (Name of Facility and Rehabilitation Education/Counseling Notice), Violations: Safety issue. Any further occurrences will result in Termination. During an interview with the DON on [DATE], at 3:45 PM, the DON confirmed LVN 1 was terminated on [DATE]. An Interview with the DON and DSD and review of policies and procedures on [DATE], indicated the following: A review of facility's policy and procedure titled, Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of [REDACTED]. A review of the facility's policy and procedure titled. Abuse Investigation and Reporting, Revised 2017, indicated . All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly invested by facility management: Findings of abuse investigation will also be reported. Role of Investigator: 1. Individual conducting the investigation will, as a minimum. b. Review the Resident's medical record to determine events leading up to the incident. J. Review all events leading up to the alleged incident. Reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property for will be reported by the facility Administrator or designee. A review of the facility's policy and procedure titled, Charge Nurse undated, indicated . The primary purpose of your job position is to provide direct nursing care to supervise the day to day nursing activities performed by nurse's assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and degree of quality care is always maintained. Must not pose a direct threat to health or safety of individuals in the workplace. A review of the facility's policy and procedure titled, Resident Rights dated [DATE], indicated . Employees shall treat all residents with kindness, respect, and dignity. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status. Revised 2017, indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/ or status; 2. A, Significant Change of change is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions: b. Impacts more than one area of the Resident's health status. A review of the facility's policy and procedure titled, Administering Medications, dated [DATE] indicated. Medications shall be administered in a safe and timely manner, and as prescribed.

Based on observation, interview, and record review, the facility failed to ensure that medications were available for administration when 83 medication doses were missed for seven of seven residents (Resident 1, 2, 3, 4, 5, 6, and 7) in a universe of 84 as follows: 1. For Resident 1: a. Xarelto (treat people with [MEDICAL CONDITION] (heart rhythm disorder) to lower their risk of getting another blood clot (gel-like clump of blood)) 10 milligrams (MG-unit of measure) one tablet in the evening by month (PO) was not administered on (MONTH) 4,6,7,12,22,27 through 30, 2019 and (MONTH) 8,9,10,15,16,21,22,26,27, 2019. Missed 18 doses. b. Pantoprazole (help with digestion) 40 MG one tablet PO before meals-not administered (MONTH) 3, two doses on the 4th, 5, two doses on the 6th, 10, 12, 14, 15, 23, 28, 29, and 30, 2019 and (MONTH) 1,3,4,8,9,10,12,13,15, two doses on the 16th, 21, 22, two doses on the 26th, and two doses on the 27, 2019. Missed 31 doses. c. [MEDICATION NAME] (used to treat high cholesterol) 20 MG one tablet PO at bedtime (HS)-not administered on (MONTH) 27, 2019. Missed one dose. d. [MEDICATION NAME] Sodium (to treat low [MEDICAL CONDITION] levels) 100 Micrograms (MCG-unit of measure) one tablet PO Daily-not administered (MONTH) 10, 11, and 27, 2019. Missed three doses. 2. For Resident 2: a. Zyprexia (to treat [MEDICAL CONDITION] (affects a person's ability to think, feel, and behave clearly)) 20 MG one tablet PO Daily-not administered (MONTH) 27 and 28, 2019. Missed two doses. b. [MEDICATION NAME] (to treat depression) 200 MG one tablet PO Daily-not administered (MONTH) 26 and 29, 2019. Missed two doses. 3. For Resident 3: a. Pantoprazole (for digestion) 40 MG one tablet PO before breakfast (AC)-not administered (MONTH) 3, 26, 27, and 28, 2019. Missed four doses. c. Rivastigmine Patch (for dementia (memory loss)) 4.6MG/24 hours apply one patch [MEDICATION NAME] daily-not administered (MONTH) 6, 12, 19, and 24, 2019. Missed four doses. d. [MEDICATION NAME] Sodium Extended Release (Treat [MEDICAL CONDITION] (abnormal brain activity)) 24 hours 250 MG one tablet PO every six hours-not administered (MONTH) 26, 2019. Missed one dose. e. [MEDICATION NAME] (used to treat high cholesterol) 40 MG one tablet PO at HS- not administered (MONTH) 17 and 18, 2019. Missed two doses. 4. For Resident 4: a.[MEDICATION NAME] HCL Extended Release (to treat high blood pressure) 240 MG one tablet PO Daily-Not administered (MONTH) 9, 20, and 21, 2019. Missed three doses. 5. For Resident 5: a. [MEDICATION NAME] (to treat heart failure) 125 MCG two tablets PO Daily-Not administered (MONTH) 27, 2019. Missed one dose. 6. For Resident 6: a. Atorvastatin Calcium (to treat high cholesterol) 40 MG one tablet PO at HS-not administered (MONTH) 5 and 6, 2019. Missed two doses. b. [MEDICATION NAME] (medication given to help rid the body of excess water) 40 MG PO one tablet twice a day-not administered (MONTH) 4, and 5, 2019. Missed two doses. 7. For Resident 7: a. [MEDICATION NAME] (to aid in digestion) 20 MG one tablet PO Daily-not administered (MONTH) 9, 2019 and (MONTH) 27, 2019. Missed two doses. b. [MEDICATION NAME] (treat pain in the nerve's in the body) 600 MG one tablet PO three times a day- missing one dose on (MONTH) 9, 2019. Missed one dose. c. [MEDICATION NAME] (for [MEDICAL CONDITION] (changes in the brains electrical activity)) 500 MG, give five Milliliters (ML-unit of measure) PO every eight hours- not administered for one dose on (MONTH) 9, one dose on 13, 2019 and one dose on (MONTH) 27, 2019. Missed three doses. These failures resulted in Residents 1,2, 3, 4, 5, 6, and 7 being placed at high risk for harm or potentially death as a result of missing 83 doses of significant medications not being administered as ordered by the physician between (MONTH) 1, 2019 through (MONTH) 28,2019. Findings: 1. A record review of Resident 1's clinical record, indicated Resident 1 was admitted to the facility on (MONTH) 12, (YEAR) with [DIAGNOSES REDACTED]. During a concurrent observation and interview of Resident 1, on (MONTH) 27, 2019, at 10:30 AM, Resident 1 was lying on his back, in bed with the head of his elevated resting with his curtain pulled. Resident 1 verbalized staff never informed him he had been missing doses of some of his medications. A review of Resident 1's Medication Administration Record (MAR-is a legal record of the drugs administered to the resident), dated (MONTH) 2019 through (MONTH) 2019 revealed the following: a. A review of Resident 1's MAR revealed Xarelto- 10 milligrams (MG-unit of measure) one tablet in the evening by month (PO) was not administered on (MONTH) 4,6,7,12,22,27, 28, 29, 30, 2019 and (MONTH) 8,9,10,15,16,21,22,26,27, 2019. b. A review of Resident 1's MAR revealed Pantoprazole -40 MG one tablet PO before meals-not administered (MONTH) 3, two doses on the 4th, 5, two doses on the 6th, 10, 12, 14, 15, 23, 28, 29, and 30, 2019 and (MONTH) 1,3,4,8,9,10,12,13,15, two doses on the 16th, 21, 22, two doses on the 26th, and two doses on the 27, 2019. c. A review of Resident 1's MAR revealed [MEDICATION NAME]-20 MG one tablet PO at bedtime (HS)-not administered on (MONTH) 27, 2019. d. A review of Resident 1's MAR revealed [MEDICATION NAME] Sodium-100 Micrograms (MCG-unit of measure) one tablet PO Daily-not administered (MONTH) 10, 11, and 27, 2019. During a review of Resident 1's MAR, dated (MONTH) 2019 through (MONTH) 2019, it revealed the following medications were not administered per physician's orders [REDACTED]. A clinical record review for Resident 1's recapitulation (physician order [REDACTED]. During an interview with RNS 1 on (MONTH) 27, 2019, at 2:08 PM, RNS 1 confirmed Resident 1 had not been administered missing significant medications in (MONTH) 2019 through (MONTH) 2019. RNS 1 stated she had not been notified by anyone that so many medication doses were not administered to Resident 1 and no documentation to verify Resident 1's physician had also been aware. RNS 1 further verified the physician should be notified in-case a resident has any adverse effects from missing medication doses. RNS 1 further stated it could be a problem with ordering and receiving medications from the pharmacy. During an interview with a Pharmacy Technician (Pharm Tech), on (MONTH) 27, 2019, at 2:15 PM, Pharm Tech confirmed the facility does not have an automated Drug Dispensing System (provides computer-controlled storage, dispensing, and tracking of medications). The Pharm Tech stated the process for ordering medications for residents who are already in the system, the facility needs to reorder medications when the supply is down to about three to five doses left. The Pharm Tech verified they deliver medications once a day except if they get orders for a resident who needs something right away. During a phone call to (Name of Pharmacy), on (MONTH) 27, 2019, 3:00 PM, the Pharmacy Consultant (PC), the PC was asked about (Name of the Facility) residents MAR's being documented with so many missing doses of medications, the PC stated not being aware there was a problem getting medications delivered. The PC verbalized they make one delivery a day unless they get an order for [REDACTED]. When questioned PC about they received some fax orders requesting missing doses, the PC stated, We do not keep those faxes once we receive them. During an interview with the DON, on (MONTH) 27, 2019, at 3:20 PM, the DON reviewed Resident 1's MAR for (MONTH) 2019 through (MONTH) 2019 and confirmed all the missing medication doses. The DON stated she was not notified by any staff and did not find any documentation that Resident 1's physician was also notified. The DON further verified with Resident 1's medical condition that is was significant to his health that he not miss any doses of his Xarelto. The DON confirmed per there, Change in a Resident's Condition or status, policy and procedure, a nurse should notify the resident's physician when a dose of medication is missed. During an interview from Licensed Vocational Nurse 1 (LVN 1), on (MONTH) 27, 2019, at 3:30 PM, LVN 1 verified he administered medications to resident 1 and was aware on several days that significant doses of medications were not available. LVN 1 stated he did not notified Resident 1's physician for any missing medication doses and is aware Resident 1's health could be compromised from not receiving his medications as ordered. During an observation of the medication cart for Resident 1's medication conducted with LVN 1, on (MONTH) 27, 2019, at 4:00 PM, Pantoprazole dose for 5:00 PM was missing from the cart and his Xarelto 5:00 PM dose was also missing from the cart. LVN 1 verified he had notified the pharmacy but, LVN 1 did not notify his physician. 2. A record review of Resident 2's clinical record, indicated Resident 2 was admitted to the facility on (MONTH) 10, 2019 with [DIAGNOSES REDACTED]. A review of Resident 2's MAR dated (MONTH) 2019 through (MONTH) 2019 revealed the following: a. A review of Resident 2's MAR revealed Zyprexia-20 MG one tablet PO Daily-not administered (MONTH) 27 and 28, 2019. b. [MEDICATION NAME]-200 MG one tablet PO Daily-not administered (MONTH) 26 and 29, 2019. A clinical record review for Resident 2's recapitulation (physician order [REDACTED]. During an interview with LVN 1 on (MONTH) 27, 2019, at 3:30 PM, LVN 1 reviewed Resident 2's MAR and confirmed the missing medication doses. LVN 1 stated he was the medication nurse for those days and the medication doses that were missed, were not delivered from the pharmacy and LVN 1 never notified the physician. During an interview with RNS 2, on (MONTH) 28, 2019, 11:30 AM, while reviewing Resident 2's MAR, RNS 2 confirmed Resident 2 was not administered [MEDICATION NAME]-200 MG one tablet PO Daily-on (MONTH) 26 and 29, 2019. RNS 2 verified when medication doses are missing the medication nurse is to notify the supervisor immediately, so the they can contact the pharmacy, physician, and monitor the resident. RNS 2 stated he was not aware that Resident 1 and 2 were missing so many doses of medications. 3. A record review of Resident 3's clinical record, indicated Resident 3 was admitted to the facility on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 3's MAR dated (MONTH) 2019 through (MONTH) 2019 revealed the following: a. A review of Resident 3's MAR revealed Pantoprazole-40 MG one tablet PO before breakfast (AC)-not administered (MONTH) 3, 26, 27, and 28, 2019. b. A review of Resident 3's MAR revealed Rivastigmine Patch-4.6MG/24 hours apply one patch [MEDICATION NAME] daily-not administered (MONTH) 6, 12, 19, and 24, 2019. c. A review of Resident 3's MAR revealed [MEDICATION NAME] Sodium Extended Release (Treat [MEDICAL CONDITION] (abnormal brain activity)) 24 hours 250 MG one tablet PO every six hours-not administered for two doses on (MONTH) 26, 2019. d. A review of Resident 3's MAR revealed [MEDICATION NAME]- 40 MG one tablet PO at HS- not administered (MONTH) 17 and 18, 2019. A clinical record review for Resident 3's recapitulation (physician order [REDACTED]. During an interview with RNS 2, on (MONTH) 28, 2019, 11:40 AM, while reviewing Resident 3's MAR, RNS 2 confirmed Resident 3 was administered Pantoprazole-40 MG one tablet PO before breakfast (AC)-on (MONTH) 3, 26, 27, and 28, 2019, Rivastigmine Patch-4.6MG/24 hours apply one patch [MEDICATION NAME] daily-on (MONTH) 6, 12, 19, and 24, 2019. [MEDICATION NAME] Sodium Extended Release (Treat [MEDICAL CONDITION] (abnormal brain activity)) 24 hours 250 MG one tablet PO every six hours-not administered for two doses on (MONTH) 26, 2019, and [MEDICATION NAME]- 40 MG one tablet PO at HS- on (MONTH) 17 and 18, 2019. RNS 2 stated he was not notified about Resident 3 missing medication doses and it should have been administered per physician's orders [REDACTED]. 4. A record review of Resident 4's clinical record, indicated Resident 4 was admitted to the facility on (MONTH) 4, 2019 with [DIAGNOSES REDACTED]. A review of Resident 4's MAR dated (MONTH) 2019 through (MONTH) 2019 revealed the following: a. A review of Resident 4's MAR revealed [MEDICATION NAME] HCL Extended Release-240 MG one tablet PO Daily-Not administered (MONTH) 9, 20, and 21, 2019. A clinical record review for Resident 4's recapitulation (physician order [REDACTED]. During an interview with RNS 2, on (MONTH) 28, 2019, 11:55 AM, while reviewing Resident 4's MAR, RNS 2 confirmed Resident 4 was not administered [MEDICATION NAME] HCL Extended Release-240 MG one tablet PO Daily- on (MONTH) 9, 20, and 21, 2019. RNS 2 stated that is a significant medication that Resident 4 should be administered. 5. A record review of Resident 5's clinical record, indicated Resident 5 was admitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident 5's MAR dated (MONTH) 2019 through (MONTH) 2019 revealed the following: a. A review of Resident 5's MAR revealed [MEDICATION NAME] (heart failure) 125 MCG two tablets PO Daily-Not administered (MONTH) 27, 2019. A clinical record review for Resident 5's recapitulation (physician order [REDACTED]. During an interview with RNS 2, on (MONTH) 28, 2019, at 12:05 PM, while reviewing Resident 5's, MAR, RNS 2 confirmed Resident 5 missed a dose of her [MEDICATION NAME] on (MONTH) 27, 2019 and was not aware about the missing dose. 6. A record review of Resident 6's clinical record, indicated Resident 6 was admitted to the facility on (MONTH) 4, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 6's MAR dated (MONTH) 2019 through (MONTH) 2019 revealed the following: a. A review of Resident 6's MAR revealed Atorvastatin Calcium-40 MG one tablet PO at HS-not administered (MONTH) 5 and 6, 2019. b. A review of Resident 6's MAR revealed [MEDICATION NAME]-40 MG PO one tablet twice a day-not administered (MONTH) 4, and 5, 2019. A clinical record review for Resident 6's recapitulation (physician order [REDACTED]. During an interview with RNS 2, on (MONTH) 28, 2019, at 12:10 PM, while reviewing Resident 6's MAR, RNS 2 confirmed Resident 6 was not administered Atorvastatin Calcium-40 MG one tablet PO at HS on (MONTH) 5 and 6, 2019 and [MEDICATION NAME]-40 MG PO one tablet twice a day on (MONTH) 4, and 5, 2019. RNS 2 stated he did know Residents 6 was missing so many doses of medications that could be dangerous to their health. During an interview with the DON, on (MONTH) 28, 2019, at 1:00 PM, the DON stated, I had no idea so many residents were missing medication doses. The DON stated, These nurses should have known better. The DON stated she going to have to do some training with staff. 7. A record review of Resident 7's clinical record, indicated Resident 7 was admitted to the facility on (MONTH) 8, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 7's MAR dated (MONTH) 2019 through (MONTH) 2019 revealed the following: a. A review of Resident 7's MAR revealed [MEDICATION NAME]-20 MG one tablet PO Daily-not administered (MONTH) 9, 2019 and (MONTH) 27, 2019. b. A review of Resident 7's MAR revealed [MEDICATION NAME]-600 MG one tablet PO three times a day- missing one dose on (MONTH) 9, 2019. c. A review of Resident 7's MAR revealed [MEDICATION NAME]-500 MG, give five Milliliters (ML-unit of measure) PO every eight hours- not administered on (MONTH) 9, and 13, 2019 and (MONTH) 27, 2019. A clinical record review for Resident 7's recapitulation (physician order [REDACTED]. During an interview with RNS 2, on (MONTH) 28, 2019, at 12:15 PM, while reviewing Resident 7'a MAR, RNS 2 confirmed Resident 7 was not administered [MEDICATION NAME]-20 MG one tablet PO Daily- on (MONTH) 9, 2019 and (MONTH) 27, 2019, [MEDICATION NAME]-600 MG one tablet PO three times a day- missing one dose on (MONTH) 9, 2019, [MEDICATION NAME]-500 MG give five Milliliters PO every eight hours on (MONTH) 9, and 13, 2019 and (MONTH) 27, 2019. RNS 2 stated he was notified of the missing doses and that could compromise her health as well and no documentation provided that Resident 7's physician was notified. During an interview with LVN 2, on (MONTH) 1, 2019, at 12:10 PM, LVN 2 stated he does pass medications on the day shift. LVN 2 stated he has had missing medication doses for the residents found during medication pass. LVN 2 verbalized he would have to contact pharmacy several times regarding the missing resident's medication doses. LVN 2 further stated he did not contact the physician if a resident missed a dose of a medication. The policy and procedure titled, Administering Medications, Revised (MONTH) 2012, indicated . The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. An Immediate Jeopardy (IJ-a situation that has threatened or is likely to threaten the health and safety of a Resident) situation was called on (MONTH) 28, 2019, at 12:20 PM, in the presence of the Director of Nurses (DON), Registered Nurse Supervisor 2 (RNS 2), and Medical Records Director 1 (MRD 1) who were verbally notified of the Immediate Jeopardy situation. Details of the Immediate Jeopardy situation including resident's health and safety at risk due to 83 missed doses of medications were provided to the DON, RNS 2 and MRD 1. Through interviews and record reviews it was verified that 83 medication doses were not administered to Resident 1,2 ,3 ,4 ,5 ,6, and 7 and no system in-place to track the medication doses that were missed. A corrective action plan was requested. The Corrective Action Plan (CAP) was provided on (MONTH) 28, 2019 at 4:00 PM. The CAP indicated an audit was conducted regarding unavailable medications, pharmacy was contacted to send them right away, a revision to, Administering Medications, policy and procedure, all nurses must be in-serviced on new P/P and the process for a missing medication, and pharmacy will be contact daily to ensure all medications will be delivered All components of the CAP were verified through observation, interview, and record review, on (MONTH) 1, 2019, at 3:00 PM, the IJ was lifted in the presence of the Administrator, DON, and the Director of Staff Development (DSD).

Based on observation, interview, and record review, the facility failed to ensure that seven of seven residents (Resident 1, 2, 3,4, 5, 6, and 7) were free from significant medication errors, when 83 doses of possible life saving medications were not administered and the facility failed to render the medication timely leading to medication being unavailable to administer. This failure had the potential to cause Resident's 1, 2, 3,4, 5, 6, and 7 to have a decline in their health possibly resulting in death. Findings: During an observation of the medication cart for Resident 1's medication conducted with Licensed Vocational Nurse 1 (LVN 1), on (MONTH) 27, 2019, at 4:00 PM, Pantoprazole (help with digestion) 40 MG one tablet by mouth (PO) before meals dose for 5:00 PM was missing from the cart and his Xarelto (treat people with [MEDICAL CONDITION]-to lower their risk of getting another blood clot (gel-like clump of blood)) 10 milligrams (MG-unit of measure) one tablet in the evening PO the 5:00 PM dose was also missing from the cart. LVN 1 verified he had notified the pharmacy but, LVN 1 did not notify his physician. A record review of Resident 1's clinical record, indicated Resident 1 was admitted to the facility on (MONTH) 12, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 1's Medication Admission Record (MAR-is a legal record of the drugs administered to the resident), dated (MONTH) 2019 through (MONTH) 2019 revealed the following: a. Xarelto 10 milligrams (MG-unit of measure) one tablet in the evening by month (PO) was not administered on (MONTH) 4th, 6th,7th, 12th, 22nd,27th through 30th, 2019 and (MONTH) 8th, 9th, 10th, 15th, 16th, 21st, 22nd, 26th, 27th, 2019. b. Pantoprazole 40 MG one tablet PO before meals-not administered (MONTH) 3, two doses on the 4th, 5th, two doses on the 6th, 10th, 12th, 14th, 15th, 23rd, 28th, 29th, and 30th, 2019 and (MONTH) 1st, 3rd, 4th, 8th, 9th, 10th, 12th, 13th, 15th, two doses on the 16th, 21st, 22nd, two doses on the 26th, and two doses on the 27th, 2019. c. [MEDICATION NAME] (high cholesterol) 20 MG one tablet PO at bedtime (HS)-not administered on (MONTH) 27, 2019. d. [MEDICATION NAME] Sodium (low [MEDICAL CONDITION] levels) 100 Micrograms (MCG-unit of measure) one tablet PO Daily-not administered (MONTH) 10th, 11th, and 27th, 2019. A clinical record review for Resident 1's recapitulation orders (physician order summary) dated (MONTH) 2019 through (MONTH) 2019 indicated the medications not administered should have been administered per physician's orders. During an interview with Registered Nurse Supervisor 1 (RNS 1) on (MONTH) 27, 2019, at 2:08 PM, RNS 1 confirmed Resident 1 had several missing significant medications doses in (MONTH) 2019 through (MONTH) 2019. RNS 1 stated she had not been notified by anyone about the missing medications, there was no documentation to verify Resident 1's physician had also been notified. RNS 1 further stated that Resident 1's health is at serious risk for missing so many doses of his Xarelto for his [MEDICAL CONDITION] Fibrillation. During an interview with the Director of Nurses (DON), on (MONTH) 27, 2019, at 3:20 PM, the DON reviewed Resident 1's MAR for (MONTH) 2019 through (MONTH) 2019 and confirmed all the missing medication doses. The DON stated she was not notified by any staff and did not find any documentation that Resident 1's physician was also notified. The DON further verified with Resident 1's medical condition that is was significant to his health that he not miss any doses of his Xarelto. The DON confirmed per their, Change in a Resident's Condition or Status, policy and procedure, a nurse should notify a resident's physician when medication doses get missed. During an interview from LVN 1, on (MONTH) 27, 2019, at 3:30 PM, LVN 1 verified he administered medications to Resident 1 and was aware on several days that significant doses of medications were not administered. LVN 1 stated he did not notify Resident 1's physician for any medication doses that were not administered and is aware that Resident 1 having [MEDICAL CONDITION] that it compromised his health. A record review of Resident 2's clinical record, indicated Resident 2 was admitted to the facility on (MONTH) 10, 2019 with [DIAGNOSES REDACTED]. A review of Resident 2's MAR dated (MONTH) 2019 through (MONTH) 2019 revealed the following: a. [MEDICATION NAME] (treat [MEDICAL CONDITION] (affects a person's ability to think, feel, and behave clearly)) 20 MG one tablet PO Daily-not administered (MONTH) 27th and 28th, 2019. b. [MEDICATION NAME] (treat depression) 200 MG one tablet PO Daily-not administered (MONTH) 26th and 29th, 2019. A clinical record review for Resident 2's recapitulation orders (physician order summary) dated (MONTH) 2019 through (MONTH) 2019 indicated the medications not administered should have been administered per physician's orders. During an interview with LVN 1 on (MONTH) 27, 2019, at 3:30 PM, LVN 1 reviewed Resident 2's MAR and confirmed the medications were not administered. LVN 1 stated he was the medication nurse for those days and the medication doses that were missed, were not delivered from the pharmacy. LVN 1 stated he did not notify the physician because it caused no harm to Resident 2. During an interview with RNS 2, on (MONTH) 28, 2019, 11:30 AM, while reviewing Resident 2's MAR, RNS 2 confirmed Resident 2 was not administered [MEDICATION NAME]-200 MG one tablet PO Daily-on (MONTH) 26th and 29th, 2019. RNS 1 verified when medication doses are missing the medication nurse is to notify the supervisor immediately, so the they can contact the pharmacy, physician, and monitor the resident. RNS 2 stated he was not aware that Resident 1 and 2 were missing so many doses of medications. A record review of Resident 3's clinical record, indicated Resident 3 was admitted to the facility on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 3's MAR dated (MONTH) 2019 through (MONTH) 2019 revealed the following: a. Pantoprazole (for digestion) 40 MG one tablet PO before (AC) breakfast-not administered (MONTH) 3rd, 26th, 27th and 28th, 2019. b. Rivastigmine Patch (for dementia (memory loss)) 4.6MG/24 hours apply one patch [MEDICATION NAME] daily-not administered (MONTH) 6th, 12th, 19th, and 24th, 2019. c. [MEDICATION NAME] Sodium Extended Release- (to treat major depressive episode) 24 hours 250 MG one tablet PO every six hours-not administered for two doses on (MONTH) 26th, 2019. d. [MEDICATION NAME] (high cholesterol) 40 MG one tablet PO at HS- not administered (MONTH) 17th and 18th, 2019. A clinical record review for Resident 3's recapitulation orders (physician order summary) dated (MONTH) 2019 through (MONTH) 2019 indicated the medications not administered should have been administered per physician's orders. During an interview with RNS 2, on (MONTH) 28, 2019, 11:40 AM, while reviewing Resident 3's MAR, RNS 2 confirmed Resident 3 was administered Pantoprazole-40 MG one tablet PO before breakfast (AC)-on (MONTH) 3, 26, 27, and 28, 2019, Rivastigmine Patch-4.6MG/24 hours apply one patch [MEDICATION NAME] daily-on (MONTH) 6, 12, 19, and 24, 2019. [MEDICATION NAME] Sodium Extended Release 24 hours 250 MG one tablet PO every six hours-not administered for two doses on (MONTH) 26, 2019, and [MEDICATION NAME]- 40 MG one tablet PO at HS- on (MONTH) 17th and 18, 2019. RNS 2 stated he was not notified about Resident 3 missing medication doses and it should have been administered per physician's order for Resident 3. A record review of Resident 4's clinical record, indicated Resident 4 was admitted to the facility on (MONTH) 4, 2019 with [DIAGNOSES REDACTED]. A review of Resident 4's MAR dated (MONTH) 2019 through (MONTH) 2019 revealed the following: a.[MEDICATION NAME] HCL Extended Release (for high blood)-240 MG one tablet PO Daily-Not administered (MONTH) 9th, 20th, and 21th, 2019. A clinical record review for Resident 4's recapitulation orders (physician order summary) dated (MONTH) 2019 through (MONTH) 2019 indicated the medication had not been administered and still has active orders. During an interview with RNS 2, on (MONTH) 28, 2019, 11:55 AM, while reviewing Resident 4's MAR, RNS 2 confirmed Resident 4 was not administered [MEDICATION NAME] HCL Extended Release-240 MG one tablet PO Daily- on (MONTH) 9th, 20th, and 21th, 2019. RNS 2 stated that is a significant medication that Resident 4 should be administered. A record review of Resident 5's clinical record, indicated Resident 5 was admitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. A record review of Resident 5's clinical record, indicated Resident 5 was admitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident 5's MAR dated (MONTH) 2019 through (MONTH) 2019 revealed the following: a. [MEDICATION NAME] (heart failure) 125 MCG two tablets PO Daily-Not administered (MONTH) 27, 2019. A clinical record review for Resident 5's recapitulation orders (physician order summary) dated (MONTH) 2019 through (MONTH) 2019 indicated the medication not administered still have an active order. During an interview with RNS 2, on (MONTH) 28, 2019, at 12:05 PM, while reviewing Resident 5's, MAR, RNS 2 confirmed Resident 5 missed a dose of her [MEDICATION NAME] on (MONTH) 27, 2019 and was not aware about the missing dose. A record review of Resident 6's clinical record, indicated Resident 6 was admitted to the facility on (MONTH) 4, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 6's MAR dated (MONTH) 2019 through (MONTH) 2019 revealed the following: a. Atorvastatin Calcium (high cholesterol) 40 MG one tablet PO at HS-not administered (MONTH) 5 and 6, 2019 b. [MEDICATION NAME] (medication given to help rid the body of excess water) 40 MG PO one tablet twice a day-not administered (MONTH) 4, and 5, 2019. A clinical record review for Resident 6's recapitulation orders (physician order summary) dated (MONTH) 2019 through (MONTH) 2019 indicated the medication not administered still have active orders. During an interview with RNS 2, on (MONTH) 28, 2019, at 12:10 PM, while reviewing Resident 6's MAR, RNS 2 confirmed Resident 6 was not administered Atorvastatin Calcium-40 MG one tablet PO at HS on (MONTH) 5th and 6, 2019 and [MEDICATION NAME]-40 MG PO one tablet twice a day on (MONTH) 4th, and 5, 2019. RNS 2 stated he was unaware Resident 6 were not administered medications timely and the facility was having difficulty ordering medications. During an interview with the DON, on (MONTH) 28, 2019, at 1:00 PM, the DON stated, I had no idea it got this bad with so many residents missing medication doses. The DON stated, These nurses should have known better. The DON stated she is going to have to do some training with staff. A record review of Resident 7's clinical record, indicated Resident 7 was admitted to the facility on (MONTH) 8, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 7's MAR dated (MONTH) 2019 through (MONTH) 2019 revealed the following: a. [MEDICATION NAME] (digestion) 20 MG one tablet PO Daily-not administered (MONTH) 9, 2019 and (MONTH) 27, 2019. b. [MEDICATION NAME] (treat pain in the nerve's in the body) 600 MG one tablet PO three times a day- missing one dose on (MONTH) 9, 2019. c. [MEDICATION NAME] (for [MEDICAL CONDITION] (changes in the brains electrical activity)) 500 MG, give five Milliliters (ML-unit of measure) PO every eight hours- not administered on (MONTH) 9, and 13, 2019 and (MONTH) 27, 2019. A clinical record review for Resident 7's recapitulation orders (physician order summary) dated (MONTH) 2019 through (MONTH) 2019 indicated the medication not administered showed active orders for those medications During an interview with RNS 2, on (MONTH) 28, 2019, at 12:15 PM, while reviewing Resident 7's MAR, RNS 2 confirmed Resident 7 was not administered [MEDICATION NAME]-20 MG one tablet PO Daily- on (MONTH) 9, 2019 and (MONTH) 27, 2019, [MEDICATION NAME]-600 MG one tablet PO three times a day- missing one dose on (MONTH) 9, 2019, [MEDICATION NAME]-500 MG give five ML PO every eight hours on (MONTH) 9, and 13, 2019 and (MONTH) 27, 2019. RNS 2 stated he was notified of the missing doses and that could compromise her health as well and no documentation provided that Resident 7's physician was notified During an interview with LVN 2, on (MONTH) 1, 2019, at 12:10 PM, LVN 2 stated he does pass medications on the day shift. LVN 2 stated he has had missing medication doses for the residents found during medication pass. LVN 2 stated he is aware the residents who have missed several doses of their medications, it could significantly affect their lives. Review of the facility policy and procedure titled, Administering Medication, dated (MONTH) 2012, indicated . Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frames.

Based on observation, interview, and record reviews, the facility administration failed to maintain the highest practicable physical, mental, and psychosocial well-being of five of 27 sampled residents (Resident 2, Resident 211, Resident 264, Resident 56, and Resident 20) and failed to prevent, report, and investigate the following: 1. Facility staff witnessed verbal abuse by the physician towards Resident 211. 2. Family member struck Resident 2 multiple times as witnessed by facility staff. 3. Resident 264 was found outside facility premises, and was hospitalized . 4. Resident 56 felt staff were retaliating against him, after he had filed a complaint with the California Department of Public Health (CDPH). 5. Facility failed to coordinate, monitor, and evaluate the provision of hospice services for Resident 20. These failures resulted in harm and had the potential for five Residents (Resident 2, Resident 211, Resident 264, Resident 56, and Resident 20) in the universe of 92 residents to experience continued physical and psychological harm. Findings: 1. During a recertification survey of the facility, on (MONTH) 30, (YEAR) at 8:00 AM, an observation of Resident 211 was made. Resident 211 was awake inside his room and in bed, covered with a personal blanket. Resident 211's breakfast tray remained untouched. During an interview with Resident 211, on (MONTH) 30, (YEAR) at 8:05 AM, he stated, I want you to have time and sit down because I have been thinking about this for so many weeks now. I feel not being safe here and threatened. Nobody protects me here. Resident 211 stated that a month ago while in the social services office, when the doctor called him an f****** (expletive) idiot and was witnessed by the social workers inside the office. Resident 211 also stated Doctor (name of the physician) was standing and I was sitting in a wheelchair when he pointed his finger in my face and told me that I am a 'f****** (expletive) idiot'. I felt so mad and so helpless because I was in a wheelchair. I felt so small. Resident 211 was tearful and kept on wiping his eyes during the conversation. He further stated, Every time that he is in the facility, I kept my distance. If I'm on the floor, I go back to my room and close my curtains so he won't see me and I won't see him. During an interview with the Director of Nursing (DON), on (MONTH) 30, (YEAR) at 2:49 PM, the DON stated that she was not aware of the incident and stated, Maybe the social workers know. Sometimes they will put my name on the note that I know, but I don't know. During an interview with the Social Worker (SW 1), on (MONTH) 1, (YEAR) at 6:40 AM, she stated The incident happened a month ago, when they had an argument. The documented incident was given to the Administrator (ADM). During an interview with the Social Worker Assistant (SWA 1), on (MONTH) 2, (YEAR) at 11:08 AM, she stated, I witnessed what had happened, and if someone told me that I am acting like an idiot, I will feel offended because that is not acceptable and not appropriate to say to someone, not at all. During an interview with the SW 1, on (MONTH) 2, (YEAR) at 11:02 AM, she stated Doctor (name of the physician) and the Resident (Resident 211) were bickering each other. The SW also stated that the ADM must be informed if there is an incident of abuse and the ADM is the one who must report to the state (California Department of Public Health). During an interview with ADM, on (MONTH) 2, (YEAR) at 3:09 PM, he stated the incident was reported to him and was not reported to CDPH office. The ADM stated, Doctor (name of the physician) did not say 'you are an idiot', he said 'you are acting like an idiot'. And I do not considered it as verbal abuse. That is why I did not report it. During an interview with SWA 1, on (MONTH) 4, (YEAR) at 9:18 AM, she stated, I was typing on my computer when the Doctor (name of the physician) and (name of SW 1) came in the office with the Resident (Resident 211) to the doorway in a wheelchair. The SWA 1 further stated Doctor (name of the physician) said to the Resident (Resident 211) 'You are acting like an idiot'. Then they (physician and Resident 211) left the office and went to the nurse station. The SWA 1 was asked about what she did after witnessing the incident, she further stated I kept on what I was doing. During an interview with SW 2, on (MONTH) 4, (YEAR) at 9:33 AM, she stated, I was in the DSD (Director of Staff Development) office when I heard the resident (Resident 211) arguing with someone. When the SW 2 was asked if she saw the situation she further stated, I did not look. I stayed in the DSD office. During a record review of Resident 211's medical records, on (MONTH) 4, (YEAR) at 10:43 AM, there was no documented follow up evidence related to Resident 211's encounter with the physician. During a record review of facility document titled, Investigative Interview Transcript - Employee signed by SW 1, dated (MONTH) 13, (YEAR), it indicated that Resident 211 and the physician were bickering (arguing) back and forth, It also indicated that the Resident 211 was given a new physician. During a record review of facility document titled, Investigative Interview Transcript - Employee signed by SWA 1, dated (MONTH) 13, (YEAR), it indicated that SWA 1 did hear the physician stated You (Resident 211) are acting like an idiot. During a record review of Resident 211's medical record, Resident 211 was admitted to the facility on (MONTH) 23, (YEAR) with admitting [DIAGNOSES REDACTED]. A review of facility document titled Resident Admission Form, dated (MONTH) 23, (YEAR) at 2:45 PM, indicated a behavioral/cognitive assessment of being alert and cooperative. A review of Minimum Data System (MDS- assessment tool for Resident), dated (MONTH) 20, (YEAR), the Section C-Cognitive Patterns in BIMS (Brief Interview for Mental Status-test given by medical professionals that helps determine a patient's cognitive understanding) is 15. The Resident has capacity to make his needs known. A review of facility document titled, Job Descriptions-Social Service Designee, indicated Administrative Functions: Work with emotional problems including assisting the resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care. A review of facility document titled, Job Descriptions-Director of Nursing Services, indicated Resident Rights: Report and investigate all allegations of resident abuse and/or misappropriation of resident property. A review of facility policy and procedure titled, Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of [REDACTED]. Abuse includes, but is not limited to physical, mental, verbal, sexual, or financial abuse or misappropriation of resident property. The facility maintains zero tolerance to any abuse to residents from anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. A review of facility policy and procedure titled, Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of [REDACTED]. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, or use of offensive language. And also indicated on page 7 of 7 Reporting: The Administrator in coordination with Compliance Officer with either verify or report all allegations of abuse or neglect in accordance with the state and federal regulations including but not limited to the Elder Justice Act. A review of the facility policy and procedure titled, Resident Rights dated (MONTH) (YEAR), indicated Policy: It is the policy of this facility to treat each resident with respect and dignity and care for each resident that recognized his or her individually. A review of facility document titled, Resident Bill of Rights, indicated The Right: 10. To be treated with consideration, respect, dignity and individuality, including privacy in treatment and in the care of personal needs. 2. A review of the clinical record of Resident 2 on (MONTH) 30, (YEAR) at 11:00 AM indicated she was admitted to the facility on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. A review of the clinical record of Resident 2 on (MONTH) 30, (YEAR) at 11:30 AM, indicated on (MONTH) 20, (YEAR), two certified nursing assistants (CNA) witnessed Resident 2 was hit multiple times by her mother during an argument between Resident 2 and her mother. Resident 2 was also hit on the face that caused her left eyebrow wound to reopen and bleed. During an observation and concurrent interview on (MONTH) 30, (YEAR) at 11:45 AM of Resident 2, she was in in bed and did not want to talk about the incident. In an interview with the Licensed Vocational Nurse 1 (LVN 1) on (MONTH) 2, (YEAR) at 1:00 PM, she stated that Resident 2 had a prearranged doctor's appointment that day . Resident 2's mother was the one who was to drive and accompany her to Resident 2's appointment in Resident 2's mother's private vehicle. LVN 1 stated that she allowed the mother to drive her daughter (Resident 2) to her doctor's appointment on the day the incident occurred. In an interview with the Director of Social Services (DSS) on (MONTH) 2, (YEAR) at 2:00 PM, she stated that she was not able to complete her investigation about the incident. The DSS stated that Adult Protective Services (APS) and police were not notified of the incident. During an interview with the Administrator on (MONTH) 2, (YEAR) at 3:00 PM, he stated he was not able to report the unusual occurrence to California Department of Public Health. The Facility's policy and procedures titled, Abuse Prevention and Prohibition Program, undated, indicated under Investigation, a. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, or injuries of an unknown source . I. the Facility will report known or suspected instances of physical abuse, including sexual abuse, to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations . 3. A review of Resident 264's face sheet (document that includes demographics and medical information), indicated that Resident 264 was admitted to the facility on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. Resident 264 has a Durable Power of Attorney for healthcare (a legal document that lets you name someone else to make decisions about your health care in case you are not able to make those decisions yourself. It gives that person (called your agent) instructions about the kinds of medical treatment you want). During a review of Resident 264's Admission packet Emergency Department (ED) notes dated (MONTH) 20, (YEAR), from an acute care hospital indicated, Presents with medics after being put on a 5150 hold by sheriffs (a 72 hold to ensure the Resident was not of harm to herself or others.) She was found wandering around confused. During an observation on (MONTH) 30, (YEAR), at 8:40 AM, Resident 264 was seen with a gait belt (a belt placed around the waist used to actively assist ambulating patients who have problems with balance) on being assisted by a physical therapy assistant (PTA, aides work under the direction and supervision of a physical therapist), as the Resident was walking in the hallway. During an observation on (MONTH) 30, (YEAR), at 2:00 PM, Resident 264 was up in the hallway being assisted by her one to one sitter (1:1 - a person assigned to watch an individual resident at the bedside for a variety of reasons, the sitter generally does not provide direct patient care). During an observation on (MONTH) 1, (YEAR), at 8:30 AM, Resident 264 was seen ambulating in the hallway with the PTA back towards her room. During an observation on (MONTH) 2, (YEAR), at 11:30 AM, Resident 264 was seen lying in her bed watching TV, there was no 1:1 sitter present at the time. The sitter came out of Resident 264's bathroom, stating I needed to use the restroom. During a review of the facility's Resident Admission Form dated (MONTH) 21, (YEAR), indicated, Resident 264 was admitted from a general acute care hospital. Resident 264 was assessed as being alert, disruptive and verbally aggressive. During a review of the Nurse's Notes dated (MONTH) 21, (YEAR) at 10:00 PM, indicated, Resident arrived via gurney, related to new admission, getting signatures, resident in with a sitter (A person, who sits, talks and interacts with patients, generally do not any patient care). During a review of the facility's Admission Assessments dated (MONTH) 21, (YEAR), in the section entitled, Safety Risk due to: Wandering; Combativeness; Other behaviors, the facility did not identify Resident 264 to be a safety risk for the above issues. The goal section included the following: 1. Monitor for behavior every shift and document any noted episodes; 2. Notify if behaviors increases; 3. adequate monitoring based on the residents condition; 4. Med's as ordered. During a review of the Nurse's Notes dated (MONTH) 23, (YEAR) at 6:00 PM, it indicated, While passing trays we noticed that the resident was not in her room, did a facility check of all rooms and bathrooms then initiated a perimeter check. Saw an EMS (emergency management system, an ambulance) vehicle at the church, investigated and found that EMS was called and they are transporting (Resident) to general acute care hospital. There is no documentation that the physician was notified regarding the elopement of the Resident. A review of the physician's orders, undated, did not indicate that an order was written for Resident 264 to have a sitter upon admission. Further review of the physician's telephone orders dated (MONTH) 23, (YEAR) at 12:45, indicated DC (discontinue) sitter services. During further review of the clinical record dated (MONTH) 23, (YEAR), indicated that Resident 264 was discharged to home against medical advice (AMA - when a person who is alert, oriented and able to make their own medical decision leaves a facility against the advice of the their doctor). Another document entitled, Interdisciplinary Team Conference (ITC) dated (MONTH) 24, (YEAR), indicated the Resident AMA / discharged out of the building without notification to staff. During an interview and concurrent record review with the Registered Nurse Supervisor (RNS) on (MONTH) 2, (YEAR) at 3:20 PM, the RNS indicated that she could not locate an order from the physician for a sitter, or that the physician was notified the resident eloped from the facility. The RNS also confirmed that the initial assessment for wander risk was incomplete. The RNS further confirmed that no plan of care was developed for Resident 264 for elopement and/or wandering behaviors. During an interview with the Physician Assistant on (MONTH) 2, (YEAR), at 11:35 (a specially trained person who is certified to provide basic medical services under the supervision of a licensed physician - PA.) The PA stated he knew she had a history of [REDACTED]. The PA stated, after I spoke with Resident 264, she said she had not been wandering, but had been locked out of the daughter's house when she was found wandering and was taken to the hospital. After we talked awhile, she stated that she was happy here and she had no plans to leave the facility, so I discontinued the one to one sitter. During an interview with the Administrator (ADM) on (MONTH) 2, (YEAR), at 11:45 AM, he indicated Resident 264 left the facility AMA. He further stated that given the information that he had on the Resident he did not feel that she had eloped she had just gone next door. The ADM defined the difference between leaving AMA and leaving the facility as an elopement. The ADM stated, If a resident is someone who has capacity and is of sound mind who decides they would like to leave the facility that they had the right to leave whenever they wanted to. The ADM further stated If someone was diagnosed with [REDACTED]. During an observation on (MONTH) 3, (YEAR), at 8:00, Resident 264 was in her bed watching TV with a 1:1 sitter at the bedside. During an observation on (MONTH) 7, (YEAR), at 2:00 PM, Resident 264 was in her bed asleep, with her 1:1 sitting at the bedside reading a book. The facility policy and procedure entitled, Elopement dated (MONTH) (YEAR), indicates It is the policy of this facility to minimize the risk of elopement and take action to locate a missing resident. Elopement is defined as When a resident who has cognitive deficits unexpectedly leaves the facility grounds and the surrounding property of the facility. An alert and orientated and/or otherwise self-responsible resident may leave the facility at any time consistent with his or her plan of care. The policy indicates in Procedures 1. Residents who are at risk for elopement (those resident with a clear history of repeated elopements will have an appropriate plan of care developed to address the risk. 6. a. The DON and ADM shall be notified. C. Notify the attending physician. F. The required oversight agencies shall be notified. 4. During an observation and interview on (MONTH) 3, (YEAR), at 8:10 AM, Resident 56 appeared to be anxious and asked this Registered Nurse (RN) if he could ask some questions regarding his rights in the facility. Resident 56 asked if he was able to eat in a dining room. He further stated I was eating in this (pointed to the dining room behind him which is used for residents who need assistance with eating) dining room and (Name) started yelling at me across the room and told me I could not eat in the dining room. (Name) told me that I was and that I was being disruptive to the rest of the staff and the other Residents and I needed to leave. Resident 56 further stated that there were two other staff who saw what happened. As the interview continued, Resident 56 continued to say over and over, Why can't I eat in the dining room. He also stated, What did I do wrong, what did I do wrong .Resident 56 stated I said something to CNA 2 who was sitting next to me that wasn't in nice that (Name) got the promotion. CNA 2, said something like yes and went back to feeding her resident. This is when (Name) (Restorative Nursing Assistant, RNA, an extended role for a certified nursing assistant, that can assist Residents with special needs) starting yelling at me, saying I was gossiping and interrupting the CNA from doing her job. Resident 56 stated, That the RNA walked out of the dining room and everything was quite for a while. Then the RNA returned and stated yelling even more, she told me to quit talking to the staff. Resident 56 stated over and over, What did I do wrong? What did I do wrong? Resident further stated that (Name) came in and told me to quiet down and told the RNA to leave. (Name) and the Charge Nurse (CN). The CN and I talked and I told her that I was never going to eat in one of the dining rooms again that I was only going to stay in my room and eat in there from now on, because they made me feel as I was doing something wrong. Resident 56 continued with interview, I was called in to the Social Services Director (SSD) after this happened. The SSD told me that I had been disruptive in the dining room today and then she told me that I had the right to eat in any dining room I want, but that one is for the other residents who need more attention when they are eating. She (SSD) told me that as long as I don't disturb others then I can eat in the room. Resident 56 stated felt as if he was being treated like a child who was being scolded and disrespected. A review of Resident 56's face sheet (document that includes demographics and medical information), indicated that Resident 56 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. During an interview on (MONTH) 3, (YEAR), at 8:45 AM with the RNA, the RNA stated Resident 56 was gossiping with another staff member at the table he was sitting, I told him to stop talking the CNA who is supposed to be feeding another resident. I also told the CNA to stop talking to the resident and to quit gossiping about other staff members. The RNA indicated that she was at one table and Resident 56 was at another table (approximately 20 feet apart), the RNA stated That he got very upset, I tried to explain to him why he shouldn't be here, but he continued to engage. I got up and left the dining room and went to report it to the SSD. I came back into the dining room and Resident 56 was talking to another resident who wanted to ask me questions about what had happened. During an interview on (MONTH) 3, (YEAR), at 8:55 AM with the SSD, the SSD stated The RNA came into tell me that Resident 56 was being disruptive in the dining room and talking to staff and gossiping. She stated, The resident came in to talk with me and we talked about the dining room rules that he can eat in either dining room as long as he is not disruptive to others. I also counseled him on appropriate behaviors. During an interview on (MONTH) 3, (YEAR), at 9:00 AM with CNA 1, the CNA stated, I was assisting in the dining room with resident feeding. Resident 56 said something like how nice it was that another staff member got a promotion, I said yes and went back to helping with my resident. Then the RNA started yelling at me not to talk to Resident 56 about personnel issues. She further stated, The RNA was acting rude and disrespectful to the both of us, yelling across the room. She was creating a scene and a conflict when there was nothing going on. I was assisting my resident and listening to Resident 56. The RNA should never have done that, she should have handled the situation better. During an interview on (MONTH) 3, (YEAR), at 11:30 AM with Charge Nurse (CN), the CN stated I heard raised voices in the dining room telling a resident that he can't be in the room, I came in a separated them and told the RNA to go talk to her supervisor. I talked to Resident 56 and told him that he should talk to the Administrator or a state surveyor if he had any other issues. The CN further stated, From what I saw the resident was not being disruptive. When the RNA returned to the dining room, she started up at it again, she was yelling and the pitch of her voice was rising, of course when then Resident 56's voice was also getting louder. I heard the RNA tell the resident that he could not eat in the dining room and talk about other people, she was quite upset. Resident 56 was done and he left the room. The CN confirmed that she had not reported the incident with anyone. During an interview on (MONTH) 3, (YEAR), at 11:45 with the Director of Staff Development (DSD) related to the incident in the dining room, the DSD stated What incident? During an observation and interview on (MONTH) 3, (YEAR), at 11:55 AM, with Resident 56, the Resident stated What did I do wrong? I am so upset I have turned off my phone, I don't want to talk to my Mom or my family, and I don't want to take this out on them. Resident appears anxious and fidgeting in his bed with the privacy curtain pulled sitting in the dark. Resident 56 continues, I always try to do the right thing, I don't understand what I did wrong. I'm never going into the dining rooms again, I felt so humiliated and felt like I was a child being scolded. He further went on to say that he overheard staff members talking saying that I'm nothing but a trouble maker after I talked to you (CDPH - RN). Resident 56 did not want to give anymore names, what else will happen. I still don't know why they did this to me. During an interview on (MONTH) 3, (YEAR), 12:20 PM, with the facility contracted Psychologist (PhD), the PhD stated I'm glad you came to me when you did, Resident 56 is very hurt, anxious, and agitated. He is verbalizing how he felt disrespected by the staff in the dining room this morning, and that the staff were yelling at him, scolding him like a child. The PhD further states Resident 56 is the most easy going resident in this building, he is mellow, he is a gentleman, and he is always trying to the right thing to fit it. A review of the PhD note dated (MONTH) 3, (YEAR), indicted Provided session in response to an incident occurring in the large dining room. Resident had been reprimanded for discussing personal business with staff members and being disruptive. He verbalized feeling humiliated and disrespected as though he were a child being scolded by his Mom. He further noted that Resident 56 was uncertain as to exactly what he did wrong. I assured Resident 56 that he had done nothing wrong. During a review of Nursing Notes for (MONTH) 3, (YEAR), nothing was documented regarding the incident. During a review of Care Plans Resident 56 is care planned for anxiety and depression. The last review of the care plan was (MONTH) 3, (YEAR), with no changes noted. During an interview on (MONTH) 4, (YEAR), at 9:15 AM with CNA 2, CNA 2 stated Resident 56 is a very friendly guy, he is easy to get along with, is very independent in his care. CNA 2 continued to say that he can be outspoken when he needs to be, if it has something to do with his care. His one thing is that he does not like to be woken up in the morning, if he is sleeping, he wants to be left alone. During an interview and concurrent record review on (MONTH) 4, (YEAR), at 9:53 AM with the SSD, the SSD stated, Resident 56 does not have any behavior issues, he is always so easy going, so when the RNA came and told me about the incident I thought it was unusual so that's why I called him in. During a review of the notes you write the resident was counseled on appropriate behavior. The SSD indicated that she had not investigated the situation prior to talking to the Resident, that she had just gone on what the RNA said. She further stated that looking back at it, the RNA, was talking a lot, saying things that I could not make out, she was talking so fast, she was yelling and was irritated. The SSD confirmed that she had not reported the incident to anyone. During an interview and concurrent record review with the Director of Nursing (DON) on (MONTH) 4, (YEAR), at 10:20 AM, the DON stated The incident yesterday (May 3, (YEAR)) was not reported to me. The DON described the facility policy on an allegation of abuse, she stated that it should have been reported, the physician should have been notified, a change of condition should have been completed and a care plan developed related to the psychological aspect of the incident. The DON confirmed that the incident was not reported to her, that there was no documentation that the physician was notified, that no change or condition or care plans were completed. A review of the facility policy and procedure entitled, Abuse Prevention and Prohibition Program, undated, indicates Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents , and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property in accordance with federal and state requirements. Policy 1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. During an observation and interview on (MONTH) 5, (YEAR) at 10:40 AM, Resident 56 approached a Health Facilities Evaluator Nurse (HFEN), stating There was another incident last night (May 4, (YEAR)) between him and a Licensed Vocational Nurse 5 (LVN). He stated LVN 5 told him he was verbally abusing CNA 4. Resident 56 stated that he felt the staff were targeting him for his complaint to the state earlier, he appeared nervous and anxious about what was going to happen to him. Resident 56 stated I feel that my previous complaint to the state had backfired on me. He stated It all started when he lost his vape (electronic cigarette) and he accused CNA 4 of taking it. Resident 56 further stated LVN 5 approached him and was verbally chastising him, he stated that when LVN 5 talked to him, he was told he was being verbally abusive to the staff. During an interview on (MONTH) 5, (YEAR) at 2:00 PM, the, LVN 5 stated I was approached by CNA 4 and told that Resident 56 was accusing him of stealing his vape. LVN 5 stated she reported the incident to the Administrator (ADM) about the incident. The ADM sent a text which stated They (the residents) have to know with state in the building, if they keep complaining, it could force us to move them elsewhere. LVN 5 stated that when she talked to Resident 56 about this, she talked to him in a nice way as she explained the text to the resident, but that Resident 56 was defensive, angry and felt he was being harassed. During a review of the Nurses Notes indicated, Resident 56 was being monitored as per the Corrected Action Plan for any negative impact to the psychosocial well-being of the resident for 72 hours. The notes did not indicate that another incident took place on (MONTH) 4, (YEAR). A review of Resident 56's Short Term Care Plan entitled 'Risk of psychological distress after verbal altercation with staff members was initiated on (MONTH) 5, (YEAR), two days after the IJ was called. A review of the Investigation Report for the allegation of abuse indicates I, the ADM was notified late morning by the surveyor of an allegation of verbal abuse from staff member (LVN) and resident at approximately 10:20 PM on (MONTH) 4, (YEAR). According to the resident, the Resident, LVN talked to me about speaking inappropriately to staff members. She (LVN) went on to say that if I was not happy here that the facility could help me find placement elsewhere. According to the LVN, she was professional, calm, and non-condescending when she spoke to the resident. She reiterated what she told him and said he was fine. I spoke with the resident in the afternoon on (MONTH) 5, (YEAR), and explained to him where the LVN's counsel came from. But I made it clear to him that this was his home and we would like it very much if he wou (TRUNCATED)

Based on observation, interview and record review, the facility failed to follow their policy on investigating and reporting to the California Department of Public Health (CDPH) an unusual occurrence when: 1. The facility failed to ensure Resident 211 to be safe and free from verbal abuse when the physician yelled at Resident 211, You are acting like an idiot. 2. Resident 2 was witnessed by the facility staff to be physically hit multiple times by a family member. These failures had the potential for these two residents to be subjected to further types of abuse in a universe of 92 residents. Findings: During a recertification survey of the facility, on (MONTH) 30, (YEAR) at 8:00 AM, an observation of Resident 211 was made. Resident 211 was awake inside his room and in bed, covered with a personal blanket. Resident 211's breakfast tray remained untouched. During an interview with Resident 211, on (MONTH) 30, (YEAR) at 8:05 AM, he stated, I want you to have time and sit down because I have been thinking about this for so many weeks now. I feel not being safe here and threatened. Nobody protects me here. Resident 211 stated that a month ago while in the social services office, when the doctor called him an f****** (expletive) idiot and was witnessed by the social workers inside the office. Resident 211 also stated Doctor (name of the physician) was standing and I was sitting in a wheelchair when he pointed his finger in my face and told me that I am a 'f****** (expletive) idiot'. I felt so mad and so helpless because I was in a wheelchair. I felt so small. Resident 211 was tearful and kept on wiping his eyes during the conversation. He further stated Every time that he is in the facility, I kept my distance. If I'm on the floor, I go back to my room and close my curtains so he won't see me and I won't see him. During an interview with the Director of Nursing (DON), on (MONTH) 30, (YEAR) at 2:49 PM, the DON stated that she was not aware of the incident and stated Maybe the social workers know. Sometimes they will put my name on the note that I know, but I don't know. During an interview with the Social Worker (SW 1), on (MONTH) 1, (YEAR) at 6:40 AM she stated The incident happened a month ago, when they had an argument. The documented incident was given to the Administrator (ADM). During an interview with the Social Worker Assistant (SWA 1), on (MONTH) 2, (YEAR) at 11:08 AM, she stated I witnessed what had happened, and if someone told me that I am acting like an idiot, I will feel offended because that is not acceptable and not appropriate to say to someone, not at all. During an interview with the SW 1, on (MONTH) 2, (YEAR) at 11:02 AM, she stated Doctor (name of the physician) and the Resident (Resident 211) were bickering each other. The SW also stated that the ADM must be informed if there is an incident of abuse and the ADM is the one who must report to the state (California Department of Public Health). During an interview with ADM, on (MONTH) 2, (YEAR) at 3:09 PM, he stated the incident was reported to him and was not reported to CDPH office. The ADM stated Doctor (name of the physician) did not say 'you are an idiot', he said 'you are acting like an idiot'. And I do not considered it as verbal abuse. That is why I did not report it. During an interview with SWA 1, on (MONTH) 4, (YEAR) at 9:18 AM, she stated I was typing on my computer when the Doctor (name of the physician) and (name of SW 1) came in the office with the Resident (Resident 211) to the doorway in a wheelchair. The SWA 1 further stated Doctor (name of the physician) said to the Resident (Resident 211) 'You are acting like an idiot'. Then they (physician and Resident 211) left the office and went to the nurse station. The SWA 1 was asked about what she did after witnessing the incident, she further stated I kept on what I was doing. During an interview with SW 2, on (MONTH) 4, (YEAR) at 9:33 AM, she stated I was in the DSD (Director of Staff Development) office when I heard the resident (Resident 211) arguing with someone. When the SW 2 was asked if she saw the situation she further stated I did not look. I stayed in the DSD office. During a record review of Resident 211's medical records, on (MONTH) 4, (YEAR) at 10:43 AM, there was no documented follow up evidence related to Resident 211's encounter with the physician. During a record review of facility document titled, Investigative Interview Transcript - Employee signed by SW 1, dated (MONTH) 13, (YEAR), it indicated that Resident 211 and the physician were bickering (arguing) back and forth, It also indicated that the Resident 211 was given a new physician. During a record review of facility document titled, Investigative Interview Transcript - Employee signed by SWA 1, dated (MONTH) 13, (YEAR), it indicated that SWA 1 did hear the physician stated You (Resident 211) are acting like an idiot. During a record review of Resident 211's medical record, Resident 211 was admitted to the facility on (MONTH) 23, (YEAR) with admitting [DIAGNOSES REDACTED]. A review of facility document titled Resident Admission Form, dated (MONTH) 23, (YEAR) at 2:45 PM, indicated a behavioral/cognitive assessment of being alert and cooperative. A review of Minimum Data System (MDS- assessment tool for Resident), dated (MONTH) 20, (YEAR), the Section C-Cognitive Patterns in BIMS (Brief Interview for Mental Status-test given by medical professionals that helps determine a patient's cognitive understanding) is 15. The Resident has capacity to make his needs known. A review of facility document titled, Job Descriptions-Social Service Designee, indicated Administrative Functions: Work with emotional problems including assisting the resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care. A review of facility document titled, Job Descriptions-Director of Nursing Services, indicated Resident Rights: Report and investigate all allegations of resident abuse and/or misappropriation of resident property. A review of facility policy and procedure titled, Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of [REDACTED]. Abuse includes, but is not limited to physical, mental, verbal, sexual, or financial abuse or misappropriation of resident property. The facility maintains zero tolerance to any abuse to residents from anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. A review of facility policy and procedure titled, Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of [REDACTED]. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, or use of offensive language. And also indicated on page 7 of 7 Reporting: The Administrator in coordination with Compliance Officer with either verify or report all allegations of abuse or neglect in accordance with the state and federal regulations including but not limited to the Elder Justice Act. A review of the facility policy and procedure titled, Resident Rights dated (MONTH) (YEAR), indicated Policy: It is the policy of this facility to treat each resident with respect and dignity and care for each resident that recognized his or her individually. A review of facility document titled, Resident Bill of Rights, indicated The Right: 10. To be treated with consideration, respect, dignity and individuality, including privacy in treatment and in the care of personal needs. The facility failed to ensure Resident 211 to be free from verbal abuse that resulted in feelings of fear, shame, degradation, and helplessness. The facility failed to identify verbal abuse, monitor and evaluate Resident 211. The facility failed to report verbal abuse. The facility failed to follow the facility policy and procedure 2. A review of the clinical record of Resident 2 on (MONTH) 30, (YEAR) at 11:00 AM indicated she was admitted to the facility on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. A review of the clinical record of Resident 2 on (MONTH) 30, (YEAR) at 11:30 AM, indicated on (MONTH) 20, (YEAR), two certified nursing assistants (CNA) witnessed Resident 2 was hit multiple times by her mother during an argument between Resident 2 and her mother. Resident 2 was also hit on the face that caused her left eyebrow wound to reopen and bleed. During an observation and concurrent interview on (MONTH) 30, (YEAR) at 11:45 AM of Resident 2, she was in in bed and did not want to talk about the incident. In an interview with the Licensed Vocational Nurse 1 (LVN 1) on (MONTH) 2, (YEAR) at 1:00 PM, she stated that Resident 2 had a prearranged doctor's appointment that day. Resident 2's mother was the one who was to drive and accompany her to Resident 2's appointment in Resident 2's mother's private vehicle. LVN 1 stated that she allowed the mother to drive her daughter (Resident 2) to her doctor's appointment on the day the incident occurred. In an interview with the Director of Social Services (DSS) on (MONTH) 2, (YEAR) at 2:00 PM, she stated that she was not able to complete her investigation about the incident. The DSS stated that Adult Protective Services (APS) and police were not notified of the incident. In an interview with the Administrator on (MONTH) 2, (YEAR) at 3:00 PM, he stated, He was not able to report the unusual occurrence to California Department of Public Health. The facility failed to report, investigate and protect Resident 2 from further abuse. The Facility's policy and procedures titled Abuse Prevention and Prohibition Program, undated, indicated under Investigation, a. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, or injuries of an unknown source . I. the Facility will report known or suspected instances of physical abuse, including sexual abuse, to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations . An Immediate Jeopardy (I J) - (A situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment or death to a resident) was called on (MONTH) 2, (YEAR) at 5:30 PM, in the presence of the Administrator and the Director of Nursing. The facility's corrective plan of action stated as follows: Administrator, or designee, will ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property in accordance with federal and state regulations. Resident accepted different following physician and physician involved will be in-serviced on abuse intervention and prevention. Resident 2 will only have supervised visits with her Mother Administrator, or designee, will interview all current Residents to rule out suspected abuse. The same tool used to interview all residents will be integrated into facilities daily (Mon.-Fri.) room rounds and reported during the daily (Mon.-Fri.) stand up meetings. Director of staff development (DSD) will in-service all staff and contracted staff, upon hire and annually/as needed on abuse intervention and prevention. Information for reporting will be made more readily available throughout the facility. All new hired employees will continue to be background checked per policy and procedure (P&P). Administrator, or designee, will meet with residents Bi-monthly to ensure that the interview tool being used by management staff during morning rounds is effective. The IJ was lifted on (MONTH) 2, (YEAR) at 9:15 PM, in the presence of the Administrator and the Director of Nursing Based on observation, interviews, and record review, the facility failed to ensure that one of 92 residents (Resident 56) was free from mental abuse and retaliation. These failures had the potential to further jeopardize the health, safety and welfare of Resident 56. Findings: During an observation and interview on (MONTH) 3, (YEAR), at 8:10 AM, Resident 56 appeared to be anxious and asked this Registered Nurse (RN) if he could ask some questions regarding his rights in the facility. Resident 56 asked if he was able to eat in a dining room. He further stated I was eating in this (pointed to the dining room behind him which is used for residents who need assistance with eating) dining room and (Name) started yelling at me across the room and told me I could not eat in the dining room. (Name) told me that I was being disruptive to the rest of the staff and the other Residents and I needed to leave. Resident 56 further stated that there were two other staff who saw what happened. As the interview continued, Resident 56 continued to say over and over, Why can't I eat in the dining room. He also stated, What did I do wrong, what did I do wrong . Resident 56 stated, I said something to CNA 2 who was sitting next to me that was nice that (Name) got the promotion. CNA 2, said something like yes and went back to feeding her resident. This is when (Name) (Restorative Nursing Assistant, RNA, an extended role for a certified nursing assistant, that can assist Residents with special needs) starting yelling at me, saying I was gossiping and interrupting the CNA from doing her job. Resident 56 stated, That the RNA walked out of the dining room and everything was quiet for a while. Then the RNA returned and started yelling even more, she told me to quit talking to the staff. Resident 56 stated over and over, What did I do wrong? What did I do wrong? Resident 56 further stated that (Name) came in and told me to quiet down and told the RNA to leave. (Name) and the Charge Nurse (CN). The CN and I talked and I told her that I was never going to eat in one of the dining rooms again that I was only going to stay in my room and eat in there from now on, because they made me feel as I was doing something wrong. Resident 56 continued with interview, I was called in to the Social Services Director (SSD) after this happened. The SSD told me that I had been disruptive in the dining room today and then she told me that I had the right to eat in any dining room I want, but that one is for the other residents who need more attention when they are eating. She (SSD) told me that as long as I don't disturb others then I can eat in the room. Resident 56 stated, I felt as if I was being treated like a child who was being scolded and disrespected. A review of Resident 56's face sheet (document that includes demographics and medical information), indicated that Resident 56 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. During an interview on (MONTH) 3, (YEAR), at 8:45 AM with the RNA, the RNA stated Resident 56 was gossiping with another staff member at the table he was sitting, I told him to stop talking the CNA who is supposed to be feeding another resident. I also told the CNA to stop talking to the resident and to quit gossiping about other staff members. The RNA indicated that she was at one table and Resident 56 was at another table (approximately 20 feet apart). The RNA stated, He got very upset, I tried to explain to him why he shouldn't be here, but he continued to engage. I got up and left the dining room and went to report it to the SSD. I came back into the dining room and Resident 56 was talking to another resident who wanted to ask me questions about what had happened. During an interview on (MONTH) 3, (YEAR), at 8:55 AM with the SSD, the SSD stated the RNA came into tell me that Resident 56 was being disruptive in the dining room and talking to staff and gossiping. She stated, The resident came in to talk with me and we talked about the dining room rules and that he can eat in either dining room as long as he is not disruptive to others. I also counseled him on appropriate behaviors. During an interview on (MONTH) 3, (YEAR), at 9:00 AM with CNA 1, the CNA stated, I was assisting in the dining room with resident feeding. Resident 56 said something like how nice it was that another staff member got a promotion, I said yes and went back to helping with my resident. Then the RNA started yelling at me not to talk to Resident 56 about personnel issues. She further stated, The RNA was acting rude and disrespectful to the both of us, yelling across the room. She was creating a scene and a conflict when there was nothing going on. I was assisting my resident and listening to Resident 56. The RNA should never have done that, she should have handled the situation better. During an interview on (MONTH) 3, (YEAR), at 11:30 AM with the Charge Nurse (CN), the CN stated I heard raised voices in the dining room telling a resident that he can't be in the room, I came in and separated them and told the RNA to go talk to her supervisor. I talked to Resident 56 and told him that he should talk to the Administrator or a state surveyor if he had any other issues. The CN further stated, From what I saw the resident was not being disruptive. When the RNA returned to the dining room, she started up at it again, she was yelling and the pitch of her voice was rising, then Resident 56's voice was also getting louder. I heard the RNA tell the resident that he could not eat in the dining room and talk about other people, she was quite upset. Resident 56 was done and he left the room. The CN confirmed that she had not reported the incident to anyone. During an interview on (MONTH) 3, (YEAR), at 11:45 AM with the Director of Staff Development (DSD) related to the incident in the dining room, the DSD stated What incident? During an observation and interview on (MONTH) 3, (YEAR), at 11:55 AM with Resident 56, the Resident stated What did I do wrong? I am so upset I have turned off my phone, I don't want to talk to my Mom or my family, and I don't want to take this out on them. Resident was observed to be anxious and fidgeting in his bed with the privacy curtain pulled, and sitting in the dark. Resident 56 continues, I always try to do the right thing, I don't understand what I did wrong. I'm never going into the dining rooms again, I felt so humiliated and felt like I was a child being scolded. He further went on to say that he overheard staff members talking saying that I'm nothing but a trouble maker after I talked to you (CDPH - RN). Resident 56 did not want to give anymore names, what else will happen. I still don't know why they did this to me. During an interview on (MONTH) 3, (YEAR), 12:20 PM with the facility contracted Psychologist (PhD), the PhD stated I'm glad you came to me when you did, Resident 56 is very hurt, anxious, and agitated. He is verbalizing how he felt disrespected by the staff in the dining room this morning, and that the staff were yelling at him, scolding him like a child. The PhD further stated, Resident 56 is the most easy going resident in this building, he is mellow, he is a gentleman, and he is always trying to the right thing to fit in. A review of the PhD note dated (MONTH) 3, (YEAR), indicted Provided session in response to an incident occurring in the large dining room. Resident had been reprimanded for discussing personnel business with staff members and being disruptive. He verbalized feeling humiliated and disrespected as though he were a child being scolded by his Mom. He further noted that Resident 56 was uncertain as to exactly he did wrong. I assured Resident 56 that he had done nothing wrong. During a review of Nursing Notes for (MONTH) 3, (YEAR), nothing was documented regarding the incident. During a review of Care Plans Resident 56 is care planned for anxiety and depression. The last review of the care plan was (MONTH) 3, (YEAR), with no changes noted. During an interview on (MONTH) 4, (YEAR), at 9:15 AM with CNA 2, CNA 2 stated Resident 56 is a very friendly guy, he is easy to get along with, is very independent in his care. CNA 2 continued to say that he can be outspoken when he needs to be, if it has something to do with his care. His one thing is that he does not like to be woken up in the morning, if he is sleeping, he wants to be left alone. During an interview and concurrent record review on (MONTH) 4, (YEAR), at 9:53 AM with the SSD, the SSD stated, Resident 56 does not have any behavior issues, he is always so easy going, so when the RNA came and told me about the incident I thought it was unusual so that's why I called him in. During a review of the notes you write the resident was counseled on appropriate behavior. The SSD indicated that she had not investigated the situation prior to talking to the Resident, that she had just gone on what the RNA said. She further stated that looking back at it, the RNA was talking a lot, saying things that I could not make out, she was talking so fast, she was yelling and was irritated. The SSD confirmed that she had not reported the incident to anyone. During an interview and concurrent record review with the Director of Nursing (DON) on (MONTH) 4, (YEAR), at 10:20 AM, the DON stated The incident yesterday (May 3, (YEAR)) was not reported to me. The DON confirmed that the incident was not reported to her, that there was no documentation that the physician was notified, that no change or condition or care plans were completed. A review of the facility policy and procedure entitled, Abuse Prevention and Prohibition Program, undated, indicates Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents , and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property in accordance with federal and state requirements. Policy 1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. An immediate Jeopardy (IJ, a situation that has threatened or is likely to threaten the health and safety of clients) was called for the following: An IJ was called under 483.12 (a) (1) Free from Abuse and Neglect, on (MONTH) 3, (YEAR), at 5:30 PM in the presence of the Administrator and the Director of Nurses. The facility failed to ensure that one resident (Resident 56) was not subjected to ongoing verbal, and mental abuse and retaliation. (Refer to F 600) The facility submitted an acceptable corrective action plan on (MONTH) 3, (YEAR), 9:30 PM in the presence of the Administrator and the Director of Nursing, with the IJ to remain in place. The corrective action plan included: 1. Staff member involved with psychosocial abuse on 05.03.18 at approximately 8:30 AM was suspended immediately upon management's awareness, pending investigation. 2. LVN Charge Nurse that incident was witnessed by and not reported properly per facilities Abuse P & P, was also suspended pending investigation. 3. Director of Nurses, or designee, (Social Services) to monitor (per shift) resident involved in incident for any negative impact to psychosocial well-being for 72 hrs. 4. Director of Staff Development (DSD) to in-service all available staff immediately on mandated reporting, respect & dignity, proper communication with residents, resident's rights and self-determination and all other areas of abuse. Staff not following proper reporting protocols per facilities Abuse Prevention P&P, will be reported to the appropriate CNA, LVN, and RN boards. The N[NAME] shift will be in-serviced by DSD, or designee, on 05.03.18 before starting their shift. The day shift on 05.04.18 will be in-serviced by the DSD, or designee, before starting their shift. This process will be repeated per shift until 100% compliance is achieved. 5. Social Services Department will lead out with monitoring resident's psychosocial needs through routine interaction with residents weekly. 6. DSD will in-service and role play with all available staff regarding Understanding Challenging Behaviors to properly address resident causes of behavior, procedures for responding to the behavior, and tips how to respond to challenging behaviors. In addition, all staff will be reminded of the Professional Culture of Nursing Services that we all have the privilege to work in. The N[NAME] shift will be in-serviced by DSD, or designee, on 05.05.18 before starting their shift. The day shift and PM shift were in-serviced on 05.05.18. This process will be repeated per shift until 100% compliance is achieved. During an observation and interview on (MONTH) 5, (YEAR) at 10:40 AM, Resident 56 approached a Health Facilities Evaluator Nurse (HFEN), stating There was another incident last night (May 4, (YEAR)) between him and a Licensed Vocational Nurse 5 (LVN). He stated LVN 5 told him he was verbally abusing CNA 4. Resident 56 stated that he felt the staff were targeting him for his complaint to the state earlier, he appeared nervous and anxious about what was going to happen to him. Resident 56 stated, I feel that my previous complaint to the state had backfired on me. He stated, It all started when he lost his vape (electronic cigarette) and he accused CNA 4 of taking it. Resident 56 further stated, LVN 5 approached him and was verbally chastising him, he stated that when LVN 5 talked to him, he was told he was being verbally abusive to the staff. During an interview on (MONTH) 5, (YEAR), at 2:00 PM, LVN 5 stated, I was approached by CNA 4 and told that Resident 56 was accusing him of stealing his vape. LVN 5 stated she reported the incident to the Administrator (ADM). The ADM sent a text which stated They (the residents) have to know with state in the building, if they keep complaining, it could force us to move them elsewhere. LVN 5 stated that when she talked to Resident 56 about this, she talked to him in a nice way as she explained the text to the resident, but that Resident 56 was defensive, angry and felt he was being harassed. A review of the Nurses Notes indicated, Resident 56 was being monitored as per the Corrected Action Plan for any negative impact to the psychosocial well-being of the resident for 72 hours. The notes did not indicate that another incident took place on (MONTH) 4, (YEAR). A review of Resident 56's Short Term Care Plan entitled 'Risk of psychological distress after verbal altercation with staff members was initiated on (MONTH) 5, (YEAR), two days after the IJ was called. A review of the Investigation Report for the allegation of abuse indicates I, the ADM was notified late morning by the surveyor of an allegation of verbal abuse from staff member (LVN) and resident at approximately 10:20 PM on (MONTH) 4, (YEAR). According to the resident, the Resident, LVN talked to me about speaking inappropriately to staff members. She (LVN) went on to say that if I was not happy here that the facility could help me find placement elsewhere. According to the LVN, she was professional, calm, and non-condescending when she spoke to the resident. She reiterated what she told him and said he was fine. I spoke with the resident in the afternoon on (MONTH) 5, (YEAR) and explained to him where the LVN's counsel came from. But I made it clear to him that this was his home and we would like it very much if he would stay and not feel that he needed to find another place to live. He agreed to hang in there for me and to personally contact me if any further issues. LVN was suspended pending investigation. The facility did not provide evidence to show the implementation of the Corrective Action Plan was put in place. On (MONTH) 7, (YEAR), at 5:00 PM an exit conference was held. The facility management was verbally notified that the Immediate Jeopardy would not be lifted, due to sub-standard quality of care and the facility was being placed on a 23 day Fast Track.

Based on observation, interview, and record review, the facility failed to follow their policy on investigating and reporting to California Department of Public Health (CDPH) an unusual occurrence when: 1.The facility failed to report physical assault of Resident 2 by a family member. 2.The facility failed to report mental and verbal abuse of Resident 56. 3.The facility failed to report the physician verbally abusing Resident 211. These failures had the potential for these three residents be subjected to further types of abuse in a universe of 92 residents. Findings: 1. A review of the clinical record of Resident 2 on (MONTH) 30, (YEAR) at 11:00 AM, indicated she was admitted to the facility on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. A review of the clinical record of Resident 2 on (MONTH) 30, (YEAR) at 11:30 AM, indicated on (MONTH) 20, (YEAR), two certified nursing assistants (CNA) witnessed Resident 2 was hit multiple times by her mother during an argument between Resident 2 and her mother. Resident 2 was also hit on the face that caused her left eyebrow wound to reopen and bleed. During an observation and concurrent interview on (MONTH) 30, (YEAR) at 11:45 AM of Resident 2, she was in in bed and did not want to talk about the incident. An interview with the Licensed Vocational Nurse 1 (LVN 1) on (MONTH) 2, (YEAR) at 1:00 PM she stated that Resident 2 had a prearranged doctor's appointment that day. Resident 2's mother was the one who was to drive and accompany her to Resident 2's appointment in Resident 2's mother's private vehicle. LVN 1 stated that she allowed the mother to drive her daughter (Resident 2) to her doctor's appointment on the day the incident occurred. An interview with the Director of Social Services (DSS) on (MONTH) 2, (YEAR) at 2:00 PM, she stated that she was not able to complete her investigation about the incident. DSS stated that Adult Protective Services (APS) and police were not notified of the incident. An interview with the Administrator on (MONTH) 2, (YEAR) at 3:00 PM, he stated I was not able to report the incident to California Department of Public Health. The Facility's policy and procedures titled Abuse Prevention and Prohibition Program, undated, indicated under Investigation, a. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, or injuries of an unknown source . I. the Facility will report known or suspected instances of physical abuse, including sexual abuse, to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations . 2. During an observation and interview on (MONTH) 3, (YEAR), at 8:10 AM, Resident 56 appeared to be anxious and asked this Registered Nurse (RN) if he could ask some questions regarding his rights in the facility. Resident 56 asked if he was able to eat in a dining room. He further stated, I was eating in this (pointed to the dining room behind him which is used for residents who need assistance with eating) dining room and (Name) started yelling at me across the room and told me I could not eat in the dining room. (Name) told me that I was and that I was being disruptive to the rest of the staff and the other residents and I needed to leave. Resident 56 further stated that there were two other staff who saw what happened. As the interview continued, Resident 56 continued to say over and over, Why can't I eat in the dining room. He also stated, What did I do wrong, what did I do wrong . Resident 56 stated, I said something to CNA 2 who was sitting next to me that wasn't in nice that (Name) got the promotion. CNA 2, said something like yes and went back to feeding her resident. This is when (Name) (Restorative Nursing Assistant, RNA, an extended role for a certified nursing assistant, that can assist Residents with special needs) starting yelling at me, saying I was gossiping and interrupting the CNA from doing her job. Resident 56 stated, That the RNA walked out of the dining room and everything was quite for a while. Then the RNA returned and stated yelling even more, she told me to quit talking to the staff. Resident 56 stated over and over, What did I do wrong? What did I do wrong? Resident further stated that (Name) came in and told me to quiet down and told the RNA to leave. (Name) and the Charge Nurse (CN). The CN and I talked and I told her that I was never going to eat in one of the dining rooms again that I was only going to stay in my room and eat in there from now on, because they made me feel as I was doing something wrong. Resident 56 continued with interview, I was called in to the Social Services Director (SSD) after this happened. The SSD told me that I had been disruptive in the dining room today and then she told me that I had the right to eat in any dining room I want, but that one is for the other residents who need more attention when they are eating. She (SSD) told me that as long as I don't disturb others then I can eat in the room. Resident 56 stated felt as if he was being treated like a child who was being scolded and disrespected. A review of Resident 56's face sheet (document that includes demographics and medical information), indicated that Resident 56 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. During an interview on (MONTH) 3, (YEAR), at 8:45 AM with the RNA, the RNA stated Resident 56 was gossiping with another staff member at the table he was sitting, I told him to stop talking the CNA who is supposed to be feeding another resident. I also told the CNA to stop talking to the resident and to quit gossiping about other staff members. The RNA indicated that she was at one table and Resident 56 was at another table (approximately 20 feet apart), the RNA stated, He got very upset, I tried to explain to him why he shouldn't be here, but he continued to engage. I got up and left the dining room and went to report it to the SSD. I came back into the dining room and Resident 56 was talking to another resident who wanted to ask me questions about what had happened. During an interview on (MONTH) 3, (YEAR), at 8:55 AM with the SSD, the SSD stated, the RNA came into tell me that Res 56 was being disruptive in the dining room and talking to staff and gossiping. She stated, The resident came in to talk with me and we talked about the dining room rules that he can eat in either dining room as long as he is not disruptive to others. I also counseled him on appropriate behaviors. During an interview on (MONTH) 3, (YEAR), at 9:00 AM with CNA 1, the CNA stated, I was assisting in the dining room with resident feeding. Resident 56 said something like how nice it was that another staff member got a promotion, I said yes and went back to helping with my resident. Then the RNA started yelling at me not to talk to Resident 56 about personnel issues. She further stated, The RNA was acting rude and disrespectful to the both of us, yelling across the room. She was creating a scene and a conflict when there was nothing going on. I was assisting my resident and listening to Resident 56. The RNA should never have done that, she should have handled the situation better. During an interview on (MONTH) 3, (YEAR), at 11:30 AM with Charge Nurse (CN), the CN stated I heard raised voices in the dining room telling a resident that he can't be in the room, I came in a separated them and told the RNA to go talk to her supervisor. I talked to Resident 56 and told him that he should talk to the Administrator or a state surveyor if he had any other issues. The CN further stated, From what I saw the resident was not being disruptive. When the RNA returned to the dining room, she started up at it again, she was yelling and the pitch of her voice was rising, of course when then Resident 56's voice was also getting louder. I heard the RNA tell the resident that he could not eat in the dining room and talk about other people, she was quite upset. Resident 56 was done and he left the room. The CN confirmed that she had not reported the incident with anyone. During an interview on (MONTH) 3, (YEAR), at 11:45 AM, with the Director of Staff Development (DSD) related to the incident in the dining room, the DSD stated What incident? During an observation and interview on (MONTH) 3, (YEAR), at 11:55 AM with Resident 56, the Resident stated What did I do wrong? I am so upset I have turned off my phone, I don't want to talk to my Mom or my family, and I don't want to take this out on them. Resident appears anxious and fidgeting in his bed with the privacy curtain pulled sitting in the dark. Resident 56 continues, I always try to do the right thing, I don't understand what I did wrong. I'm never going into the dining rooms again, I felt so humiliated and felt like I was a child being scolded. He further went on to say that he overheard staff members talking saying that I'm nothing but a trouble maker after I talked to you (CDPH - RN). Resident 56 did not want to give anymore names, what else will happen. I still don't know why they did this to me.' During an interview on (MONTH) 3, (YEAR), 12:20 PM with the facility contracted Psychologist (PhD), the PhD stated I'm glad you came to me when you did, Resident 56 is very hurt, anxious, and agitated. He is verbalizing how he felt disrespected by the staff in the dining room this morning, and that the staff were yelling at him, scolding him like a child. The PhD further stated Resident 56 is the most easy going resident in this building, he is mellow, he is a gentleman, and he is always trying to the right thing to fit it. A review of the PhD note dated (MONTH) 3, (YEAR), indicted Provided session in response to an incident occurring in the large dining room. Resident had been reprimanded for discussing personal business with staff members and being disruptive. He verbalized feeling humiliated and disrespected as though he were a child being scolded by his Mom. He further noted that Resident 56 was uncertain as to exactly he did wrong. I assured Resident 56 that he had done nothing wrong. During a review of Nursing Notes for (MONTH) 3, (YEAR), nothing was documented regarding the incident. During a review of Care Plans Resident 56 is care planned for anxiety and depression. The last review of the care plan was (MONTH) 3, (YEAR), with no changes noted. During an interview on (MONTH) 4, (YEAR), at 9:15 AM with CNA 2, CNA 2 stated Resident 56 is a very friendly guy, he is easy to get along with, is very independent in his care. CNA 2 continued to say that he can be outspoken when he needs to be, if it has something to do with his care. His one thing is that he does not like to be woken up in the morning, if he is sleeping, he wants to be left alone. During an interview and concurrent record review on (MONTH) 4, (YEAR), at 9:53 AM with the SSD, the SSD stated, Resident 56 does not have any behavior issues, he is always so easy going, so when the RNA came and told me about the incident I thought it was unusual so that's why I called him in. During a review of the notes you write the resident was counseled on appropriate behavior. The SSD indicated that she had not investigated the situation prior to talking to the Resident, that she had just gone on what the RNA said. She further stated that looking back at it, the RNA, was talking a lot, saying things that I could not make out, she was talking so fast, she was yelling and was irritated. The SSD confirmed that she had not reported the incident to anyone. During an interview and concurrent record review with the Director of Nursing (DON) on (MONTH) 4, (YEAR), at 10:20 AM, the DON stated The incident yesterday (May 3, (YEAR)) was not reported to me. The DON described the facility policy on an allegation of abuse, she stated that it should have been reported, the physician should have been notified, a change of condition should have been completed and a care plan developed related to the psychological aspect of the incident. The DON confirmed that the incident was not reported to her, that there was no documentation that the physician was notified, that no change or condition or care plans were completed. During an observation and interview on (MONTH) 5, (YEAR) at 10:40 AM, Resident 56 approached a Health Facilities Evaluator Nurse (HFEN), stating There was another incident last night (May 4, (YEAR)) between him and a Licensed Vocational Nurse 5 (LVN). He stated LVN 5 told him he was verbally abusing CNA 4. Resident 56 stated that he felt the staff were targeting him for his complaint to the state earlier, he appeared nervous and anxious about what was going to happen to him. Resident 56 stated, I feel that my previous complaint to the state had backfired on me. He stated It all started when he lost his vape (electronic cigarette) and he accused CNA 4 of taking it. Resident 56 further stated LVN 5 approached him and was verbally chastising him, he stated that when LVN 5 talked to him, he was told he was being verbally abusive to the staff. During an interview on (MONTH) 5, (YEAR), at 2:00 PM the, LVN 5 stated I was approached by CNA 4 and told that Resident 56 was accusing him of stealing his vape. LVN 5 stated she reported the incident to the Administrator (ADM) about the incident. The ADM sent a text which stated They (the residents) have to know with state in the building, if they keep complaining, it could force us to move them elsewhere. LVN 5 stated that when she talked to Resident 56 about this, she talked to him in a nice way as she explained the text to the resident, but that Resident 56 was defensive, angry and felt he was being harassed. During a review of the Nurses Notes indicated, Resident 56 was being monitored as per the Corrected Action Plan for any negative impact to the psychosocial well-being of the resident for 72 hours. The notes did not indicate that another incident took place on (MONTH) 4, (YEAR). A review of Resident 56's Short Term Care Plan entitled 'Risk of psychological distress after verbal altercation with staff members was initiated on (MONTH) 5, (YEAR), two days after the IJ was called. A review of the Investigation Report for the allegation of abuse indicates I, the ADM was notified late morning by the surveyor of an allegation of verbal abuse from staff member (LVN) and resident at approximately 10:20 PM on (MONTH) 4, (YEAR). According to the resident, the Resident, LVN talked to me about speaking inappropriately to staff members. She (LVN) went on to say that if I was not happy here that the facility could help me find placement elsewhere. According to the LVN, she was professional, calm, and non-condescending when she spoke to the resident. She reiterated what she told him and said he was fine. I spoke with the resident in the afternoon on (MONTH) 5, (YEAR) and explained to him where the LVN's counsel came from. But I made it clear to him that this was his home and we would like it very much if he would stay and not feel that he needed to find another place to live. He agreed to hang in there for me and to personally contact me if any further issues. LVN was suspended pending investigation. A review of the facility policy and procedure entitled, Abuse Prevention and Prohibition Program, undated, indicates Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents , and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property in accordance with federal and state requirements. Policy 1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. 3. During a recertification survey of the facility, on (MONTH) 30, (YEAR) at 8:00 AM, an observation of Resident 211 was made. Resident 211 was awake inside his room and in bed, covered with a personal blanket. Resident 211's breakfast tray remained untouched. During an interview with Resident 211, on (MONTH) 30, (YEAR) at 8:05 AM, he stated, I want you to have time and sit down because I have been thinking about this for so many weeks now. I feel not being safe here and threatened. Nobody protects me here. Resident 211 stated that a month ago while in the social services office, when the doctor called him an f****** (expletive) idiot and was witnessed by the social workers inside the office. Resident 211 also stated Doctor (name of the physician) was standing and I was sitting in a wheelchair when he pointed his finger in my face and told me that I am a 'f****** (expletive) idiot'. I felt so mad and so helpless because I was in a wheelchair. I felt so small. Resident 211 was tearful and kept on wiping his eyes during the conversation. He further stated, Every time that he is in the facility, I kept my distance. If I'm on the floor, I go back to my room and close my curtains so he won't see me and I won't see him. During an interview with the Director of Nursing (DON), on (MONTH) 30, (YEAR) at 2:49 PM, the DON stated that she was not aware of the incident and stated Maybe the social workers know. Sometimes they will put my name on the note that I know, but I don't know. During an interview with the Social Worker (SW 1), on (MONTH) 1, (YEAR) at 6:40 AM, she stated The incident happened a month ago, when they had an argument. The documented incident was given to the Administrator (ADM). During an interview with the Social Worker Assistant (SWA 1), on (MONTH) 2, (YEAR) at 11:08 AM, she stated I witnessed what had happened, and if someone told me that I am acting like an idiot, I will feel offended because that is not acceptable and not appropriate to say to someone, not at all. During an interview with the SW 1, on (MONTH) 2, (YEAR) at 11:02 AM, she stated Doctor (name of the physician) and the Resident (Resident 211) were bickering each other. The SW also stated that the ADM must be informed if there is an incident of abuse and the ADM is the one who must report to the state (California Department of Public Health). During an interview with ADM, on (MONTH) 2, (YEAR) at 3:09 PM, he stated the incident was reported to him and was not reported to CDPH office. The ADM stated Doctor (name of the physician) did not say 'you are an idiot', he said 'you are acting like an idiot'. And I do not considered it as verbal abuse. That is why I did not report it. During an interview with SWA 1, on (MONTH) 4, (YEAR) at 9:18 AM, she stated I was typing on my computer when the Doctor (name of the physician) and (name of SW 1) came in the office with the Resident (Resident 211) to the doorway in a wheelchair. The SWA 1 further stated Doctor (name of the physician) said to the Resident (Resident 211) 'You are acting like an idiot'. Then they (physician and Resident 211) left the office and went to the nurse station. The SWA 1 was asked about what she did after witnessing the incident, she further stated I kept on what I was doing. During an interview with SW 2, on (MONTH) 4, (YEAR) at 9:33 AM, she stated I was in the DSD (Director of Staff Development) office when I heard the resident (Resident 211) arguing with someone. When the SW 2 was asked if she saw the situation she further stated I did not look. I stayed in the DSD office. During a record review of Resident 211's medical records, on (MONTH) 4, (YEAR) at 10:43 AM, there was no documented follow up evidence related to Resident 211's encounter with the physician. During a record review of facility document titled, Investigative Interview Transcript - Employee signed by SW 1, dated (MONTH) 13, (YEAR), it indicated that Resident 211 and the physician were bickering (arguing) back and forth, It also indicated that the Resident 211 was given a new physician. During a record review of facility document titled, Investigative Interview Transcript - Employee signed by SWA 1, dated (MONTH) 13, (YEAR), it indicated that SWA 1 did hear the physician stated You (Resident 211) are acting like an idiot. During a record review of Resident 211's medical record, Resident 211 was admitted to the facility on (MONTH) 23, (YEAR) with admitting [DIAGNOSES REDACTED]. A review of facility document titled Resident Admission Form, dated (MONTH) 23, (YEAR) at 2:45 PM, indicated a behavioral/cognitive assessment of being alert and cooperative. A review of Minimum Data System (MDS- assessment tool for Resident), dated (MONTH) 20, (YEAR), the Section C-Cognitive Patterns in BIMS (Brief Interview for Mental Status-test given by medical professionals that helps determine a patient's cognitive understanding) is 15. The Resident has capacity to make his needs known. A review of facility document titled, Job Descriptions-Social Service Designee, indicated Administrative Functions: Work with emotional problems including assisting the resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care. A review of facility document titled, Job Descriptions-Director of Nursing Services, indicated Resident Rights: Report and investigate all allegations of resident abuse and/or misappropriation of resident property. A review of facility policy and procedure titled, Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of [REDACTED]. Abuse includes, but is not limited to physical, mental, verbal, sexual, or financial abuse or misappropriation of resident property. The facility maintains zero tolerance to any abuse to residents from anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. A review of facility policy and procedure titled, Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of [REDACTED]. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, or use of offensive language. And also indicated on page 7 of 7 Reporting: The Administrator in coordination with Compliance Officer with either verify or report all allegations of abuse or neglect in accordance with the state and federal regulations including but not limited to the Elder Justice Act. A review of the facility policy and procedure titled, Resident Rights dated (MONTH) (YEAR), indicated Policy: It is the policy of this facility to treat each resident with respect and dignity and care for each resident that recognized his or her individually. A review of facility document titled, Resident Bill of Rights, indicated The Right: 10. To be treated with consideration, respect, dignity and individuality, including privacy in treatment and in the care of personal needs. During a record review of Resident 211's medical records, there was no documented evidence related to Resident 211's encounter with the physician that was reported.

Based on observation, interview, and record review, the facility failed to ensure prevention, identification, thorough investigation, and reporting of abuse, neglect, and mistreatment of [REDACTED]. 1. The facility staff witnessed verbal abuse by the physician towards Resident 211. 2. Resident 56 felt staff were retaliating against him, after he had filed a complaint with the California Department of Public Health (CDPH). 3. A family member struck Resident 2 multiple times as witnessed by facility staff. These failures resulted to physical and psychological harm to three residents. Findings: 1. During a recertification survey of the facility, on (MONTH) 30, (YEAR) at 8:00 AM, an observation of Resident 211 was made. Resident 211 was awake inside his room and in bed, covered with a personal blanket. Resident 211's breakfast tray remained untouched. During an interview with Resident 211, on (MONTH) 30, (YEAR) at 8:05 AM, he stated, I want you to have time and sit down because I have been thinking about this for so many weeks now. I feel not being safe here and threatened. Nobody protects me here. Resident 211 stated that a month ago while in the social services office, when the doctor called him an f****** (expletive) idiot and was witnessed by the social workers inside the office. Resident 211 also stated Doctor (name of the physician) was standing and I was sitting in a wheelchair when he pointed his finger in my face and told me that I am a 'f****** (expletive) idiot'. I felt so mad and so helpless because I was in a wheelchair. I felt so small. Resident 211 was tearful and kept on wiping his eyes during the conversation. He further stated Every time that he is in the facility, I kept my distance. If I'm on the floor, I go back to my room and close my curtains so he won't see me and I won't see him. During an interview with the Director of Nursing (DON), on (MONTH) 30, (YEAR) at 2:49 PM, the DON stated that she was not aware of the incident and stated Maybe the social workers know. Sometimes they will put my name on the note that I know, but I don't know. During an interview with the Social Worker (SW 1), on (MONTH) 1, (YEAR) at 6:40 AM she stated The incident happened a month ago, when they had an argument. The documented incident was given to the Administrator (ADM). During an interview with the Social Worker Assistant (SWA 1), on (MONTH) 2, (YEAR) at 11:08 AM, she stated I witnessed what had happened, and if someone told me that I am acting like an idiot, I will feel offended because that is not acceptable and not appropriate to say to someone, not at all. During an interview with the SW 1, on (MONTH) 2, (YEAR) at 11:02 AM, she stated Doctor (name of the physician) and the Resident (Resident 211) were bickering each other. The SW also stated that the ADM must be informed if there is an incident of abuse and the ADM is the one who must report to the state (California Department of Public Health). During an interview with ADM, on (MONTH) 2, (YEAR) at 3:09 PM, he stated the incident was reported to him and was not reported to CDPH office. The ADM stated Doctor (name of the physician) did not say 'you are an idiot', he said 'you are acting like an idiot'. And I do not considered it as verbal abuse. That is why I did not report it. During an interview with SWA 1, on (MONTH) 4, (YEAR) at 9:18 AM, she stated I was typing on my computer when the Doctor (name of the physician) and (name of SW 1) came in the office with the Resident (Resident 211) to the doorway in a wheelchair. The SWA 1 further stated Doctor (name of the physician) said to the Resident (Resident 211) 'You are acting like an idiot'. Then they (physician and Resident 211) left the office and went to the nurse station. The SWA 1 was asked about what she did after witnessing the incident, she further stated I kept on what I was doing. During an interview with SW 2, on (MONTH) 4, (YEAR) at 9:33 AM, she stated I was in the DSD (Director of Staff Development) office when I heard the resident (Resident 211) arguing with someone. When the SW 2 was asked if she saw the situation she further stated I did not look. I stayed in the DSD office. During a record review of Resident 211's medical records, on (MONTH) 4, (YEAR) at 10:43 AM, there was no documented follow up and no reported evidence related to Resident 211's encounter with the physician. During a record review of Resident 211's medical records, there was no documented evidence related to Resident 211's encounter with the physician that was reported. During a record review of facility document titled, Investigative Interview Transcript - Employee signed by SW 1, dated (MONTH) 13, (YEAR), it indicated that Resident 211 and the physician were bickering (arguing) back and forth, It also indicated that the Resident 211 was given a new physician. During a record review of facility document titled, Investigative Interview Transcript - Employee signed by SWA 1, dated (MONTH) 13, (YEAR), it indicated that SWA 1 did hear the physician stated You (Resident 211) are acting like an idiot. During a record review of Resident 211's medical record, Resident 211 was admitted to the facility on (MONTH) 23, (YEAR) with admitting [DIAGNOSES REDACTED]. A review of facility document titled Resident Admission Form, dated (MONTH) 23, (YEAR) at 2:45 PM, indicated a behavioral/cognitive assessment of being alert and cooperative. A review of Minimum Data System (MDS- assessment tool for Resident), dated (MONTH) 20, (YEAR), the Section C-Cognitive Patterns in BIMS (Brief Interview for Mental Status-test given by medical professionals that helps determine a patient's cognitive understanding) is 15. The Resident has capacity to make his needs known. A review of facility document titled, Job Descriptions-Social Service Designee, indicated Administrative Functions: Work with emotional problems including assisting the resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care. A review of facility document titled, Job Descriptions-Director of Nursing Services, indicated Resident Rights: Report and investigate all allegations of resident abuse and/or misappropriation of resident property. A review of facility policy and procedure titled, Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of [REDACTED]. Abuse includes, but is not limited to physical, mental, verbal, sexual, or financial abuse or misappropriation of resident property. The facility maintains zero tolerance to any abuse to residents from anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. A review of facility policy and procedure titled, Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of [REDACTED]. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, or use of offensive language. And also indicated on page 7 of 7 Reporting: The Administrator in coordination with Compliance Officer with either verify or report all allegations of abuse or neglect in accordance with the state and federal regulations including but not limited to the Elder Justice Act. A review of the facility policy and procedure titled, Resident Rights dated (MONTH) (YEAR), indicated Policy: It is the policy of this facility to treat each resident with respect and dignity and care for each resident that recognized his or her individually. A review of facility document titled, Resident Bill of Rights, indicated The Right: 10. To be treated with consideration, respect, dignity and individuality, including privacy in treatment and in the care of personal needs. 2. During an observation and interview on (MONTH) 3, (YEAR), at 8:10 AM, Resident 56 appeared to be anxious and asked this Registered Nurse (RN) if he could ask some questions regarding his rights in the facility. Resident 56 asked if he was able to eat in a dining room. He further stated I was eating in this (pointed to the dining room behind him which is used for residents who need assistance with eating) dining room and (Name) started yelling at me across the room and told me I could not eat in the dining room. (Name) told me that I was and that I was being disruptive to the rest of the staff and the other Residents and I needed to leave. Resident 56 further stated that there were two other staff who saw what happened. As the interview continued, Resident 56 continued to say over and over, Why can't I eat in the dining room. He also stated, What did I do wrong, what did I do wrong . Resident 56 stated I said something to CNA 2 who was sitting next to me that wasn't in nice that (Name) got the promotion. CNA 2, said something like yes and went back to feeding her resident. This is when (Name) (Restorative Nursing Assistant, RNA, an extended role for a certified nursing assistant, that can assist Residents with special needs) starting yelling at me, saying I was gossiping and interrupting the CNA from doing her job. Resident 56 stated, That the RNA walked out of the dining room and everything was quite for a while. Then the RNA returned and stated yelling even more, she told me to quit talking to the staff. Resident 56 stated over and over, What did I do wrong? What did I do wrong? Resident further stated that (Name) came in and told me to quiet down and told the RNA to leave. (Name) and the Charge Nurse (CN). The CN and I talked and I told her that I was never going to eat in one of the dining rooms again that I was only going to stay in my room and eat in there from now on, because they made me feel as I was doing something wrong. Resident 56 continued with interview, I was called in to the Social Services Director (SSD) after this happened. The SSD told me that I had been disruptive in the dining room today and then she told me that I had the right to eat in any dining room I want, but that one is for the other residents who need more attention when they are eating. She (SSD) told me that as long as I don't disturb others then I can eat in the room. Resident 56 stated felt as if he was being treated like a child who was being scolded and disrespected. A review of Resident 56's face sheet (document that includes demographics and medical information), indicated that Resident 56 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. During an interview on (MONTH) 3, (YEAR), at 8:45 AM with the RNA, the RNA stated Resident 56 was gossiping with another staff member at the table he was sitting, I told him to stop talking the CNA who is supposed to be feeding another resident. I also told the CNA to stop talking to the resident and to quit gossiping about other staff members. The RNA indicated that she was at one table and Resident 56 was at another table (approximately 20 feet apart), the RNA stated That he got very upset, I tried to explain to him why he shouldn't be here, but he continued to engage. I got up and left the dining room and went to report it to the SSD. I came back into the dining room and Resident 56 was talking to another resident who wanted to ask me questions about what had happened. During an interview on (MONTH) 3, (YEAR), at 8:55 AM with the SSD, the SSD stated the RNA came into tell me that Res 56 was being disruptive in the dining room and talking to staff and gossiping. She stated, The resident came in to talk with me and we talked about the dining room rules that he can eat in either dining room as long as he is not disruptive to others. I also counseled him on appropriate behaviors. During an interview on (MONTH) 3, (YEAR), at 9:00 AM with CNA 1, the CNA stated, I was assisting in the dining room with resident feeding. Resident 56 said something like how nice it was that another staff member got a promotion, I said yes and went back to helping with my resident. Then the RNA started yelling at me not to talk to Resident 56 about personnel issues. She further stated, The RNA was acting rude and disrespectful to the both of us, yelling across the room. She was creating a scene and a conflict when there was nothing going on. I was assisting my resident and listening to Resident 56. The RNA should never have done that, she should have handled the situation better. During an interview on (MONTH) 3, (YEAR), at 11:30 AM with Charge Nurse (CN), the CN stated I heard raised voices in the dining room telling a resident that he can't be in the room, I came in a separated them and told the RNA to go talk to her supervisor. I talked to Resident 56 and told him that he should talk to the Administrator or a state surveyor if he had any other issues. The CN further stated, From what I saw the resident was not being disruptive. When the RNA returned to the dining room, she started up at it again, she was yelling and the pitch of her voice was rising, of course when then Resident 56's voice was also getting louder. I heard the RNA tell the resident that he could not eat in the dining room and talk about other people, she was quite upset. Resident 56 was done and he left the room. The CN confirmed that she had not reported the incident with anyone. During an interview on (MONTH) 3, (YEAR), at 11:45 with the Director of Staff Development (DSD) related to the incident in the dining room, the DSD stated What incident? During an observation and interview on (MONTH) 3, (YEAR), at 11:55 AM with Resident 56, the Resident stated What did I do wrong? I am so upset I have turned off my phone, I don't want to talk to my Mom or my family, and I don't want to take this out on them. Resident appears anxious and fidgeting in his bed with the privacy curtain pulled sitting in the dark. Resident 56 continues, I always try to do the right thing, I don't understand what I did wrong. I'm never going into the dining rooms again, I felt so humiliated and felt like I was a child being scolded. He further went on to say that he overheard staff members talking saying that I'm nothing but a trouble maker after I talked to you (CDPH - RN). Resident 56 did not want to give anymore names, what else will happen. I still don't know why they did this to me.' During an interview on (MONTH) 3, (YEAR), 12:20 PM with the facility contracted Psychologist (PhD), the PhD stated I'm glad you came to me when you did, Resident 56 is very hurt, anxious, and agitated. He is verbalizing how he felt disrespected by the staff in the dining room this morning, and that the staff were yelling at him, scolding him like a child. The PhD further states Resident 56 is the most easy going resident in this building, he is mellow, he is a gentleman, and he is always trying to the right thing to fit it. A review of the PhD note dated (MONTH) 3, (YEAR), indicted Provided session in response to an incident occurring in the large dining room. Resident had been reprimanded for discussing personal business with staff members and being disruptive. He verbalized feeling humiliated and disrespected as though he were a child being scolded by his Mom. He further noted that Resident 56 was uncertain as to exactly he did wrong. I assured Resident 56 that he had done nothing wrong. During a review of Nursing Notes for (MONTH) 3, (YEAR), nothing was documented regarding the incident. During a review of Care Plans Resident 56 is care planned for anxiety and depression. The last review of the care plan was (MONTH) 3, (YEAR), with no changes noted. During an interview on (MONTH) 4, (YEAR), at 9:15 AM with CNA 2, CNA 2 stated Resident 56 is a very friendly guy, he is easy to get along with, is very independent in his care. CNA 2 continued to say that he can be outspoken when he needs to be, if it has something to do with his care. His one thing is that he does not like to be woken up in the morning, if he is sleeping, he wants to be left alone. During an interview and concurrent record review on (MONTH) 4, (YEAR), at 9:53 AM with the SSD, the SSD stated, Resident 56 does not have any behavior issues, he is always so easy going, so when the RNA came and told me about the incident I thought it was unusual so that's why I called him in. During a review of the notes you write the resident was counseled on appropriate behavior. The SSD indicated that she had not investigated the situation prior to talking to the Resident, that she had just gone on what the RNA said. She further stated that looking back at it, the RNA, was talking a lot, saying things that I could not make out, she was talking so fast, she was yelling and was irritated. The SSD confirmed that she had not reported the incident to anyone. During an interview and concurrent record review with the Director of Nursing (DON) on (MONTH) 4, (YEAR), at 10:20 AM, the DON stated, The incident yesterday (May 3, (YEAR)) was not reported to me. The DON described the facility policy on an allegation of abuse, she stated that it should have been reported, the physician should have been notified, a change of condition should have been completed and a care plan developed related to the psychological aspect of the incident. The DON confirmed that the incident was not reported to her, that there was no documentation that the physician was notified, that no change or condition or care plans were completed. A review of the facility policy and procedure entitled, Abuse Prevention and Prohibition Program, undated, indicates Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents , and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property in accordance with federal and state requirements. Policy 1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. During an observation and interview on (MONTH) 5, (YEAR) at 10:40 AM, Resident 56 approached a Health Facilities Evaluator Nurse (HFEN), stating There was another incident last night (May 4, (YEAR)) between him and a Licensed Vocational Nurse 5 (LVN). He stated LVN 5 told him he was verbally abusing CNA 4. Resident 56 stated that he felt the staff were targeting him for his complaint to the state earlier, he appeared nervous and anxious about what was going to happen to him. Resident 56 stated, I feel that my previous complaint to the state had backfired on me. He stated It all started when he lost his vape (electronic cigarette) and he accused CNA 4 of taking it. Resident 56 further stated LVN 5 approached him and was verbally chastising him, he stated that when LVN 5 talked to him, he was told he was being verbally abusive to the staff. During an interview on (MONTH) 5, (YEAR), at 2:00 PM the, LVN 5 stated I was approached by CNA 4 and told that Resident 56 was accusing him of stealing his vape. LVN 5 stated she reported the incident to the Administrator (ADM) about the incident. The ADM sent a text which stated They (the residents) have to know with state in the building, if they keep complaining, it could force us to move them elsewhere. LVN 5 stated that when she talked to Resident 56 about this, she talked to him in a nice way as she explained the text to the resident, but that Resident 56 was defensive, angry and felt he was being harassed. During a review of the Nurses Notes indicated, Resident 56 was being monitored as per the Corrected Action Plan for any negative impact to the psychosocial well-being of the resident for 72 hours. The notes did not indicate that another incident took place on (MONTH) 4, (YEAR). A review of Resident 56's Short Term Care Plan entitled 'Risk of psychological distress after verbal altercation with staff members was initiated on (MONTH) 5, (YEAR), two days after the IJ was called. A review of the Investigation Report for the allegation of abuse indicates I, the ADM was notified late morning by the surveyor of an allegation of verbal abuse from staff member (LVN) and resident at approximately 10:20 PM on (MONTH) 4, (YEAR). According to the resident, the Resident, LVN talked to me about speaking inappropriately to staff members. She (LVN) went on to say that if I was not happy here that the facility could help me find placement elsewhere. According to the LVN, she was professional, calm, and non-condescending when she spoke to the resident. She reiterated what she told him and said he was fine. I spoke with the resident in the afternoon on (MONTH) 5, (YEAR) and explained to him where the LVN's counsel came from. But I made it clear to him that this was his home and we would like it very much if he would stay and not feel that he needed to find another place to live. He agreed to hang in there for me and to personally contact me if any further issues. LVN was suspended pending investigation. 3. A review of the clinical record of Resident 2 on (MONTH) 30, (YEAR) at 11:00 AM indicated she was admitted to the facility on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. A review of the clinical record of Resident 2 on (MONTH) 30, (YEAR) at 11:30 AM, indicated on (MONTH) 20, (YEAR), two certified nursing assistants (CNA) witnessed Resident 2 was hit multiple times by her mother during an argument between Resident 2 and her mother. Resident 2 was also hit on the face that caused her left eyebrow wound to reopen and bleed. During an observation and concurrent interview on (MONTH) 30, (YEAR) at 11:45 AM of Resident 2, she was in in bed and did not want to talk about the incident. An interview with the Licensed Vocational Nurse 1 (LVN 1) on (MONTH) 2, (YEAR) at 1:00 PM she stated that Resident 2 had a prearranged doctor's appointment that day . Resident 2's mother was the one who was to drive and accompany her to Resident 2's appointment in Resident 2's mother's private vehicle. LVN 1 stated that she allowed the mother to drive her daughter (Resident 2) to her doctor's appointment on the day the incident occurred. An interview with the Director of Social Services (DSS) on (MONTH) 2, (YEAR) at 2:00 PM, she stated that she was not able to complete her investigation about the incident. DSS stated that Adult Protective Services (APS) and police were not notified of the incident. An interview with the Administrator on (MONTH) 2, (YEAR) at 3:00 PM, he stated he was not able to report the unusual occurrence to California Department of Public Health. The Facility's policy and procedures titled Abuse Prevention and Prohibition Program, undated, indicated under Investigation, a. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, or injuries of an unknown source . I. the Facility will report known or suspected instances of physical abuse, including sexual abuse, to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations .

Based on observation, interviews, and record review, the facility failed to provide supervision to ensure the safety of two of 92 Residents (Resident 264 and Resident 265). 1. Resident 264 had a history of [REDACTED].>2. Resident 265 was at risk for elopement. This failure resulted in the potential for harm to Resident 264 and Resident 265. Findings: 1. A review of Resident 264's face sheet (document that includes demographics and medical information), indicated that Resident 264 was admitted to the facility on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. Resident 264 has a Durable Power of Attorney for healthcare (a legal document that lets you name someone else to make decisions about your health care in case you are not able to make those decisions yourself. It gives that person (called your agent) instructions about the kinds of medical treatment you want). During a review of Resident 264's Admission packet Emergency Department (ED) notes dated (MONTH) 20, (YEAR), from an acute care hospital indicated, Presents with medics after being put on a 5150 hold by sheriffs (a 72 hold to ensure the Resident was not of harm to herself or others.) She was found wandering around confused. During an observation on (MONTH) 30, (YEAR), at 8:40 AM, Resident 264 was seen with a gait belt (a belt placed around the waist used to actively assist ambulating patients who have problems with balance) and was assisted by a physical therapy assistant (PTA, aides work under the direction and supervision of a physical therapist), as the Resident was walking in the hallway. During an observation on (MONTH) 30, (YEAR), at 2:00 PM, Resident 264 was up in the hallway being assisted by her one to one sitter (1:1 - a person assigned to watch an individual resident at the bedside for a variety of reasons, the sitter generally does not provide direct patient care). During an observation on (MONTH) 1, (YEAR), at 8:30 AM, Resident 264 was seen ambulating in the hallway with the PTA back towards her room. During an observation on (MONTH) 2, (YEAR), at 11:30 AM, Resident 264 was seen lying in her bed watching TV, there was no 1:1 sitter present at the time. The sitter came out of Resident 264's bathroom, stating I needed to use the restroom. During a review of the facility's Resident Admission Form dated (MONTH) 21, (YEAR), indicated, Resident 264 was admitted from a general acute care hospital. Resident 264 was assessed as being alert, disruptive and verbally aggressive. During a review of the Nurse's Notes dated (MONTH) 21, (YEAR), at 10:00 PM indicated, Resident arrived via gurney, related to new admission, getting signatures, resident in with a sitter (A person, who sits, talks and interacts with patients, generally do not any patient care). During a review of the facility's Admission Assessments dated (MONTH) 21, (YEAR), in the section entitled, Safety Risk due to: Wandering; Combativeness; Other behaviors, the facility did not identify Resident 264 to be a safety risk for the above issues. The goal section included the following: 1. Monitor for behavior every shift and document any noted episodes; 2. Notify if behaviors increases; 3. adequate monitoring based on the residents condition; 4. Med's as ordered. A review of the Nurse's Notes dated (MONTH) 23, (YEAR) at 6:00 PM, indicated, While passing trays we noticed that the resident was not in her room, did a facility check of all rooms and bathrooms then initiated a perimeter check. Saw an EMS (emergency management system, an ambulance) vehicle at the church, investigated and found that EMS was called and they are transporting (Resident) to general acute care hospital. There is no documentation that the physician was notified regarding the elopement of the Resident. A review of the physician's orders, undated, do not indicate that an order was written for Resident 264 to have a sitter upon admission. Further review of the physician's telephone orders dated (MONTH) 23, (YEAR) at 12:45, indicated DC (discontinue) sitter services. During further review of the clinical record dated (MONTH) 23, (YEAR), indicated that Resident 264 was discharged to home against medical advice (AMA - when a person who is alert, oriented and able to make their own medical decision leaves a facility against the advice of the their doctor). Another document entitled, Interdisciplinary Team Conference (ITC) dated (MONTH) 24, (YEAR), indicated the Resident AMA / discharged out of the building without notification to staff. During an interview and concurrent record review with the Registered Nurse Supervisor (RNS) on (MONTH) 2, (YEAR) at 3:20 PM, the RNS indicated that she could not locate an order from the physician for a sitter, or that the physician was notified the resident eloped from the facility. The RNS also confirmed that the initial assessment for wander risk was incomplete. The RNS further confirmed that no plan of care was developed for Resident 264 for elopement and/or wandering behaviors. During an interview with the Physician Assistant on (MONTH) 2, (YEAR), at 11:35 (a specially trained person who is certified to provide basic medical services under the supervision of a licensed physician - PA), the PA stated he knew she had a history of [REDACTED]. The PA stated after I spoke with Resident 264, she said she had not been wandering, but had been locked out of the daughter's house when she was found wandering and was taken to the hospital. The PA stated, After we talked awhile, she stated that she was happy here and she had no plans to leave the facility, so I discontinued the one to one sitter. During an interview with the Administrator (ADM) on (MONTH) 2, (YEAR), at 11:45 AM, he indicated Resident 264 left the facility AMA. He further stated that given the information that he had on the Resident he did not feel that she had eloped she had just gone next door. The ADM defined the difference between leaving AMA and leaving the facility as an elopement. The ADM stated, If a resident is someone who has capacity and is of sound mind who decides they would like to leave the facility that they had the right to leave whenever they wanted to. The ADM further stated If someone was diagnosed with [REDACTED]. During an observation on (MONTH) 3, (YEAR), at 8:00, Resident 264 was in her bed watching TV with a 1:1 at the bedside. During an observation on (MONTH) 7, (YEAR), at 2:00 PM, Resident 264 was in her bed asleep, with her 1:1 sitting at the bedside reading a book. The facility policy and procedure entitled, Elopement dated (MONTH) (YEAR), indicates It is the policy of this facility to minimize the risk of elopement and take action to locate a missing resident. Elopement is defined as When a resident who has cognitive deficits unexpectedly leaves the facility grounds and the surrounding property of the facility. An alert and orientated and/or otherwise self-responsible resident may leave the facility at any time consistent with his or her plan of care. The policy indicates in Procedures 1. Residents who are at risk for elopement (those resident with a clear history of repeated elopements will have an appropriate plan of care developed to address the risk. 6. a. The DON and ADM shall be notified. C. Notify the attending physician. F. The required oversight agencies shall be notified. 2. A review of Resident 265's face sheet (document that contains demographics and medical information) indicated, Resident 265 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. During an observation of Resident 265 on (MONTH) 30, (YEAR), at 9:00 AM, the resident was located in her room asleep on top of a mattress on the floor. During an interview with Certified Nurse's Assistant 5 (CNA) on (MONTH) 30, (YEAR), at 9:02 AM, she indicated that she heard that the resident did not feel that she deserved a bed and preferred to lay on the ground. During an observation of Resident 265 on (MONTH) 30, (YEAR) at 1:20 PM, Resident 265 was seen ambulating, she was up and dressed in a robe with a CNA 5 following closely behind her. Resident 265 appeared to be pulling at her diapers. The CNA 5 assisted the resident to her room, where she jumped onto the mattress on the floor and stated that she was going to take a nap. A review of Resident 265's physician's orders dated (MONTH) 25, (YEAR), indicated the following: a. Provide a sitter b. Monitor agitation as manifested by verbalization of being agitated A review of Resident 265 physician's telephone orders with various dates, indicated the following: a. (MONTH) 26, (YEAR), at 9:00 AM - Clarification: [MEDICATION NAME] (an antipsychotic medication, used to treat the symptoms of psychotic conditions such as [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder.) 5 mg (milligrams) every four hours, IM (intramuscularly - into the muscle), when necessary for 14 days for [MEDICAL CONDITION] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) manifested by verbalizations of not deserving of a bed. DC (DC-discontinue) monitor side effects, DC monitor episodes (no description of given of side effects or episodes.) b. (MONTH) 28, (YEAR), undated, indicated, [MEDICATION NAME] 1 mg by mouth every at bedtime; [MEDICATION NAME] 1 mg by mouth three times a day when needed for combative behavior. c. (MONTH) 29, (YEAR), undated, (MONTH) have psychologist for evaluation and treatment. During a review of the facility's Admission Assessments dated (MONTH) 26, (YEAR), in the section entitled, Safety Risk due to: Wandering; Combativeness; Other behaviors, the facility identified Resident 265 to be a safety risk for combativeness. The goal section included the following: 1. Monitor for behavior every shift and document any noted episodes; 2. Notify if behaviors increases; 3. adequate monitoring based on the residents condition; 4. Med's as ordered. A further review of the Admission assessment dated (MONTH) 27, (YEAR), section entitled Actual / Potential Concern Elopement was identified as a potential concern. The goal indicated that Resident will remain safely within the facility. The following interventions were listed Shadow Checks every 30 minutes, and monitor all exits. During an observation on (MONTH) 30, (YEAR), at 4:30 PM, Resident 265 was in her bed asleep, there was no sitter present. During an observation on (MONTH) 1, (YEAR), at 7:50 AM, Resident 265 was not located in the room, and no personal items were present. During an observation on (MONTH) 1, (YEAR), at 11:30 AM, Resident 265 was in a high bed, with a full bolster mattress (A mattress with firm arms and legs side which inhibits a resident's freedom of movement.) The resident had been moved to another room, right next to an exit door, no 1:1 sitter was present. During an interview and concurrent record review of the physician's orders with the Registered Nurse Supervisor 3 (RNS 3) on (MONTH) 2, (YEAR), at 12:10 PM, the RNS 3 confirmed that there was no physician order for [REDACTED]. During an interview and concurrent review of the Nursing Notes with the RNS, dated (MONTH) 25, (YEAR) through (MONTH) 2, (YEAR), did not indicate that Resident 265's physician was notified regarding behaviors other than refusal of medication and taking vital signs that would led to the physician giving an order for [REDACTED]. During an observation on (MONTH) 1, (YEAR) at 6:20 PM, Resident 265 was observed in the hallway walking toward the nursing station. Resident 265 was heard saying I'm hungry can I get a cup of coffee. A CNA approached her and assisted her toward the cart that contained coffee and then back to her room. During an observation on (MONTH) 2, (YEAR), at 10:45 AM, Resident 265 was seen, naked and attempting to go out of the exit out the door located right next to her room. During an interview, concurrent record review and room check with RNS 3 on (MONTH) 2, (YEAR), at 5:50 PM the RNS 3 stated, The recording of the shadow checks should be on a piece of paper in the residents room or in the residents chart. A review of the clinical record and the resident's room indicated there was no documented evidence to show that monitoring by shadow checks every 30 minutes was completed in accordance with the Admission Assessment document. During a review of Resident 265's care plans, no care plans were created for the identified concern of elopement. During an observation on (MONTH) 2, (YEAR), at 5:00 PM, Resident 265's bed was stripped down to the mattress. During an interview on (MONTH) 2, (YEAR), at 5:10 with RNS 1, RNS 1 indicated that Resident 265 had been transferred to another facility. During a review of the physicians orders dated (MONTH) 2, (YEAR) at 4:06 PM indicated PT (patient) to dc to (facility name) with medications. During an interview and concurrent record review with the Director of Nurses (DON) on (MONTH) 3, (YEAR), at 13:30 AM, the DON explained the facility policy on the use of any restraints in the facility. The DON stated the interdisciplinary group should have been held to assess the risks and benefits of the restraints, she further stated that a physician's order and consent should have be obtained prior to use and that a care plan should have been developed. The DON confirmed that all the above procedures were not taken prior to using physical restraints and that the use of a Bolster mattress in the record that was used, would be considered a physical restraint. The facility policy and procedure entitled Restraints dated (MONTH) (YEAR), indicates It is the policy of this facility to not use physical restrain for convenience or discipline and not required to treat a resident's medical condition. Procedure indicates 1. Assess resident's need for restrain use and document the assessment; 2. Obtain physician's order for restraint and verify informed consent. Restraints may not be applied until the physician has obtained informed consent and the facility has verified such consent (absent emergencies as to the immediate health and safety danger to a resident or other residents but this must be clearly documented); 3. Develop a plan of care for type of restraint, reason for use, and method of application. An IJ was called under 483.25 (d) (2) for Quality of Care: Free of Accident, Hazards/ Supervision/ Devices, on (MONTH) 02, (YEAR), at 5:10 PM in the presence of the Administrator and the Director of Nursing. The facility failed to ensure that for two residents (Resident 264 and 265) received adequate supervision and assistance to prevent an elopement from the facility. (Refer to F689) The IJ was lifted after an acceptable corrective action plan was received and approved on (MONTH) 2, (YEAR), at 9:15 PM in the presence of the Administrator and the Director of Nursing. The corrective action plan included: A. Resident 265 was discharged to a locked facility at approximately 5:20 PM. B. Resident 264 will have a sitter 24/7 until a more appropriate facility can be found C. The Director of Nurses, or designee, will make sure that the facility has adequate staff to ensure the health, safety and well-being, of all residents at risk for elopement. D. Upon admission to the facility the resident history and physical will be reviewed by the Director of Staff Development, or designee, and care staff will be in-serviced to the resident's needs. E. New Admission will be placed on 72 hours monitoring for adaptation to the facility and for exit seeking behaviors. If resident presents with exit seeking behaviors the ITD will review residents need to ensure that the facility can continue to meet the needs of said resident. If residents exit seeking behavior cannot be maintained at facility, then the IDT will find proper placement.

Based on observation, interview, and record review, the facility failed to ensure implementation of abuse policies and procedures for three of 27 sampled residents (Resident 211, Resident 56, and Resident 2) in a universe of 92 residents when: 1. The facility failed to report verbal abuse of the physician to Resident 211; 2. Resident 56 felt staff were retaliating against him, after he had filed a complaint with the California Department of Public Health (CDPH). 3. The family member struck Resident 2 multiple times as witnessed by facility staff. These failures resulted in physical and mental abuse of the residents. Findings: During a recertification survey of the facility, on (MONTH) 30, (YEAR) at 8:00 AM, an observation of Resident 211 was made. Resident 211 was awake inside his room and in bed, covered with a personal blanket. Resident 211's breakfast tray remained untouched. During an interview with Resident 211, on (MONTH) 30, (YEAR) at 8:05 AM, he stated, I want you to have time and sit down because I have been thinking about this for so many weeks now. I feel not being safe here and threatened. Nobody protects me here. Resident 211 stated that a month ago while in the social services office, when the doctor called him an f****** (expletive) idiot and was witnessed by the social workers inside the office. Resident 211 also stated Doctor (name of the physician) was standing and I was sitting in a wheelchair when he pointed his finger in my face and told me that I am a 'f****** (expletive) idiot'. I felt so mad and so helpless because I was in a wheelchair. I felt so small. Resident 211 was tearful and kept on wiping his eyes during the conversation. He further stated, Every time that he is in the facility, I kept my distance. If I'm on the floor, I go back to my room and close my curtains so he won't see me and I won't see him. During an interview with the Director of Nursing (DON), on (MONTH) 30, (YEAR) at 2:49 PM, the DON stated that she was not aware of the incident and stated Maybe the social workers know. Sometimes they will put my name on the note that I know, but I don't know. During an interview with the Social Worker (SW 1), on (MONTH) 1, (YEAR) at 6:40 AM she stated The incident happened a month ago, when they had an argument. The documented incident was given to the Administrator (ADM). During an interview with the Social Worker Assistant (SWA 1), on (MONTH) 2, (YEAR) at 11:08 AM, she stated I witnessed what had happened, and if someone told me that I am acting like an idiot, I will feel offended because that is not acceptable and not appropriate to say to someone, not at all. During an interview with the SW 1, on (MONTH) 2, (YEAR) at 11:02 AM, she stated Doctor (name of the physician) and the Resident (Resident 211) were bickering each other. The SW also stated that the ADM must be informed if there is an incident of abuse and the ADM is the one who must report to the state (California Department of Public Health). During an interview with ADM, on (MONTH) 2, (YEAR) at 3:09 PM, he stated the incident was reported to him and was not reported to CDPH office. The ADM stated Doctor (name of the physician) did not say 'you are an idiot', he said 'you are acting like an idiot'. And I do not considered it as verbal abuse. That is why I did not report it. During an interview with SWA 1, on (MONTH) 4, (YEAR) at 9:18 AM, she stated I was typing on my computer when the Doctor (name of the physician) and (name of SW 1) came in the office with the Resident (Resident 211) to the doorway in a wheelchair. The SWA 1 further stated Doctor (name of the physician) said to the Resident (Resident 211) 'You are acting like an idiot'. Then they (physician and Resident 211) left the office and went to the nurse station. The SWA 1 was asked about what she did after witnessing the incident, she further stated I kept on what I was doing. During an interview with SW 2, on (MONTH) 4, (YEAR) at 9:33 AM, she stated I was in the DSD (Director of Staff Development) office when I heard the resident (Resident 211) arguing with someone. When the SW 2 was asked if she saw the situation she further stated I did not look. I stayed in the DSD office. During a record review of Resident 211's medical records, on (MONTH) 4, (YEAR) at 10:43 AM, there was no documented follow up evidence related to Resident 211's encounter with the physician. During a record review of facility document titled, Investigative Interview Transcript - Employee signed by SW 1, dated (MONTH) 13, (YEAR), it indicated that Resident 211 and the physician were bickering (arguing) back and forth, It also indicated that the Resident 211 was given a new physician. During a record review of facility document titled, Investigative Interview Transcript - Employee signed by SWA 1, dated (MONTH) 13, (YEAR), it indicated that SWA 1 did hear the physician stated You (Resident 211) are acting like an idiot. During a record review of Resident 211's medical record, Resident 211 was admitted to the facility on (MONTH) 23, (YEAR) with admitting [DIAGNOSES REDACTED]. A review of facility document titled Resident Admission Form, dated (MONTH) 23, (YEAR) at 2:45 PM, indicated a behavioral/cognitive assessment of being alert and cooperative. A review of Minimum Data System (MDS- assessment tool for Resident), dated (MONTH) 20, (YEAR), the Section C-Cognitive Patterns in BIMS (Brief Interview for Mental Status-test given by medical professionals that helps determine a patient's cognitive understanding) is 15. The Resident has capacity to make his needs known. A review of facility document titled, Job Descriptions-Social Service Designee, indicated Administrative Functions: Work with emotional problems including assisting the resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care. A review of facility document titled, Job Descriptions-Director of Nursing Services, indicated Resident Rights: Report and investigate all allegations of resident abuse and/or misappropriation of resident property. A review of facility policy and procedure titled, Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of [REDACTED]. Abuse includes, but is not limited to physical, mental, verbal, sexual, or financial abuse or misappropriation of resident property. The facility maintains zero tolerance to any abuse to residents from anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. A review of facility policy and procedure titled, Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of [REDACTED]. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, or use of offensive language. And also indicated on page 7 of 7 Reporting: The Administrator in coordination with Compliance Officer with either verify or report all allegations of abuse or neglect in accordance with the state and federal regulations including but not limited to the Elder Justice Act. A review of the facility policy and procedure titled, Resident Rights dated (MONTH) (YEAR), indicated Policy: It is the policy of this facility to treat each resident with respect and dignity and care for each resident that recognized his or her individually. A review of facility document titled, Resident Bill of Rights, indicated The Right: 10. To be treated with consideration, respect, dignity and individuality, including privacy in treatment and in the care of personal needs. During a record review of Resident 211's medical records, there was no documented evidence related to Resident 211's encounter with the physician that was reported. 2. During an observation and interview on (MONTH) 3, (YEAR), at 8:10 AM, Resident 56 appeared to be anxious and asked this Registered Nurse (RN) if he could ask some questions regarding his rights in the facility. Resident 56 asked if he was able to eat in a dining room. He further stated I was eating in this (pointed to the dining room behind him which is used for residents who need assistance with eating) dining room and (Name) started yelling at me across the room and told me I could not eat in the dining room. (Name) told me that I was and that I was being disruptive to the rest of the staff and the other Residents and I needed to leave. Resident 56 further stated that there were two other staff who saw what happened. As the interview continued, Resident 56 continued to say over and over, Why can't I eat in the dining room. He also stated, What did I do wrong, what did I do wrong .Resident 56 stated I said something to CNA 2 who was sitting next to me that wasn't in nice that (Name) got the promotion. CNA 2, said something like yes and went back to feeding her resident. This is when (Name) (Restorative Nursing Assistant, RNA, an extended role for a certified nursing assistant, that can assist Residents with special needs) starting yelling at me, saying I was gossiping and interrupting the CNA from doing her job. Resident 56 stated, That the RNA walked out of the dining room and everything was quite for a while. Then the RNA returned and stated yelling even more, she told me to quit talking to the staff. Resident 56 stated over and over, What did I do wrong? What did I do wrong? Resident further stated that (Name) came in and told me to quiet down and told the RNA to leave. (Name) and the Charge Nurse (CN). The CN and I talked and I told her that I was never going to eat in one of the dining rooms again that I was only going to stay in my room and eat in there from now on, because they made me feel as I was doing something wrong. Resident 56 continued with interview, I was called in to the Social Services Director (SSD) after this happened. The SSD told me that I had been disruptive in the dining room today and then she told me that I had the right to eat in any dining room I want, but that one is for the other residents who need more attention when they are eating. She (SSD) told me that as long as I don't disturb others then I can eat in the room. Resident 56 stated felt as if he was being treated like a child who was being scolded and disrespected. A review of Resident 56's face sheet (document that includes demographics and medical information), indicated that Resident 56 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. During an interview on (MONTH) 3, (YEAR), at 8:45 AM with the RNA, the RNA stated Resident 56 was gossiping with another staff member at the table he was sitting, I told him to stop talking the CNA who is supposed to be feeding another resident. I also told the CNA to stop talking to the resident and to quit gossiping about other staff members. The RNA indicated that she was at one table and Resident 56 was at another table (approximately 20 feet apart), the RNA stated, That he got very upset, I tried to explain to him why he shouldn't be here, but he continued to engage. I got up and left the dining room and went to report it to the SSD. I came back into the dining room and Resident 56 was talking to another resident who wanted to ask me questions about what had happened. During an interview on (MONTH) 3, (YEAR), at 8:55 AM with the SSD, the SSD stated, the RNA came into tell me that Res 56 was being disruptive in the dining room and talking to staff and gossiping. She stated, The resident came in to talk with me and we talked about the dining room rules that he can eat in either dining room as long as he is not disruptive to others. I also counseled him on appropriate behaviors. During an interview on (MONTH) 3, (YEAR), at 9:00 AM with CNA 1, the CNA stated, I was assisting in the dining room with resident feeding. Resident 56 said something like how nice it was that another staff member got a promotion, I said yes and went back to helping with my resident. Then the RNA started yelling at me not to talk to Resident 56 about personnel issues. She further stated, The RNA was acting rude and disrespectful to the both of us, yelling across the room. She was creating a scene and a conflict when there was nothing going on. I was assisting my resident and listening to Resident 56. The RNA should never have done that, she should have handled the situation better. During an interview on (MONTH) 3, (YEAR), at 11:30 AM with Charge Nurse (CN), the CN stated I heard raised voices in the dining room telling a resident that he can't be in the room, I came in a separated them and told the RNA to go talk to her supervisor. I talked to Resident 56 and told him that he should talk to the Administrator or a state surveyor if he had any other issues. The CN further stated, From what I saw the resident was not being disruptive. When the RNA returned to the dining room, she started up at it again, she was yelling and the pitch of her voice was rising, of course when then Resident 56's voice was also getting louder. I heard the RNA tell the resident that he could not eat in the dining room and talk about other people, she was quite upset. Resident 56 was done and he left the room. The CN confirmed that she had not reported the incident with anyone. During an interview on (MONTH) 3, (YEAR), at 11:45 with the Director of Staff Development (DSD) related to the incident in the dining room, the DSD stated What incident? During an observation and interview on (MONTH) 3, (YEAR), at 11:55 AM with Resident 56, the Resident stated What did I do wrong? I am so upset I have turned off my phone, I don't want to talk to my Mom or my family, and I don't want to take this out on them. Resident appears anxious and fidgeting in his bed with the privacy curtain pulled sitting in the dark. Resident 56 continues, I always try to do the right thing, I don't understand what I did wrong. I'm never going into the dining rooms again, I felt so humiliated and felt like I was a child being scolded. He further went on to say that he overheard staff members talking saying that I'm nothing but a trouble maker after I talked to you (CDPH - RN). Resident 56 did not want to give anymore names, what else will happen. I still don't know why they did this to me. During an interview on (MONTH) 3, (YEAR), 12:20 PM with the facility contracted Psychologist (PhD), the PhD stated I'm glad you came to me when you did, Resident 56 is very hurt, anxious, and agitated. He is verbalizing how he felt disrespected by the staff in the dining room this morning, and that the staff were yelling at him, scolding him like a child. The PhD further states Resident 56 is the most easy going resident in this building, he is mellow, he is a gentleman, and he is always trying to the right thing to fit it. A review of the PhD note dated (MONTH) 3, (YEAR), indicated Provided session in response to an incident occurring in the large dining room. Resident had been reprimanded for discussing personal business with staff members and being disruptive. He verbalized feeling humiliated and disrespected as though he were a child being scolded by his Mom. He further noted that Resident 56 was uncertain as to exactly he did wrong. I assured Resident 56 that he had done nothing wrong. During a review of Nursing Notes for (MONTH) 3, (YEAR), nothing was documented regarding the incident. During a review of Care Plans Resident 56 is care planned for anxiety and depression. The last review of the care plan was (MONTH) 3, (YEAR), with no changes noted. During an interview on (MONTH) 4, (YEAR), at 9:15 AM with CNA 2, CNA 2 stated Resident 56 is a very friendly guy, he is easy to get along with, is very independent in his care. CNA 2 continued to say that he can be outspoken when he needs to be, if it has something to do with his care. His one thing is that he does not like to be woken up in the morning, if he is sleeping, he wants to be left alone. During an interview and concurrent record review on (MONTH) 4, (YEAR), at 9:53 AM with the SSD, the SSD stated, Resident 56 does not have any behavior issues, he is always so easy going, so when the RNA came and told me about the incident I thought it was unusual so that's why I called him in. During a review of the notes you write The resident was counseled on appropriate behavior. The SSD indicated that she had not investigated the situation prior to talking to the Resident, that she had just gone on what the RNA said. She further stated that looking back at it, the RNA, was talking a lot, saying things that I could not make out, she was talking so fast, she was yelling and was irritated. The SSD confirmed that she had not reported the incident to anyone. During an interview and concurrent record review with the Director of Nursing (DON) on (MONTH) 4, (YEAR), at 10:20 AM, the DON stated The incident yesterday (May 3, (YEAR)) was not reported to me. The DON described the facility policy on an allegation of abuse, she stated that it should have been reported, the physician should have been notified, a change of condition should have been completed and a care plan developed related to the psychological aspect of the incident. The DON confirmed that the incident was not reported to her, that there was no documentation that the physician was notified, that no change or condition or care plans were completed. During an observation and interview on (MONTH) 5, (YEAR) at 10:40 AM, Resident 56 approached a Health Facilities Evaluator Nurse (HFEN), stating There was another incident last night (May 4, (YEAR)) between him and a Licensed Vocational Nurse 5 (LVN). He stated LVN 5 told him he was verbally abusing CNA 4. Resident 56 stated that he felt the staff were targeting him for his complaint to the state earlier, he appeared nervous and anxious about what was going to happen to him. Resident 56 stated I feel that my previous complaint to the state had backfired on me. He stated It all started when he lost his vape (electronic cigarette) and he accused CNA 4 of taking it. Resident 56 further stated LVN 5 approached him and was verbally chastising him, he stated that when LVN 5 talked to him, he was told he was being verbally abusive to the staff. During an interview on (MONTH) 5, (YEAR), at 2:00 PM the, LVN 5 stated I was approached by CNA 4 and told that Resident 56 was accusing him of stealing his vape. LVN 5 stated she reported the incident to the Administrator (ADM) about the incident. The ADM sent a text which stated They (the residents) have to know with state in the building, if they keep complaining, it could force us to move them elsewhere. LVN 5 stated that when she talked to Resident 56 about this, she talked to him in a nice way as she explained the text to the resident, but that Resident 56 was defensive, angry and felt he was being harassed. During a review of the Nurses Notes indicated, Resident 56 was being monitored as per the Corrected Action Plan for any negative impact to the psychosocial well-being of the resident for 72 hours. The notes did not indicate that another incident took place on (MONTH) 4, (YEAR). A review of Resident 56's Short Term Care Plan entitled 'Risk of psychological distress after verbal altercation with staff members was initiated on (MONTH) 5, (YEAR), two days after the IJ was called. A review of the Investigation Report for the allegation of abuse indicates I, the ADM was notified late morning by the surveyor of an allegation of verbal abuse from staff member (LVN) and resident at approximately 10:20 PM on (MONTH) 4, (YEAR). According to the resident, the Resident, LVN talked to me about speaking inappropriately to staff members. She (LVN) went on to say that if I was not happy here that the facility could help me find placement elsewhere. According to the LVN, she was professional, calm, and non-condescending when she spoke to the resident. She reiterated what she told him and said he was fine. I spoke with the resident in the afternoon on (MONTH) 5, (YEAR) and explained to him where the LVN's counsel came from. But I made it clear to him that this was his home and we would like it very much if he would stay and not feel that he needed to find another place to live. He agreed to hang in there for me and to personally contact me if any further issues. LVN was suspended pending investigation. A review of the facility policy and procedure entitled, Abuse Prevention and Prohibition Program, undated, indicates Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents , and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property in accordance with federal and state requirements. Policy 1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. 3. A review of the clinical record of Resident 2 on (MONTH) 30, (YEAR) at 11:00 AM, indicated she was admitted to the facility on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. A review of the clinical record of Resident 2 on (MONTH) 30, (YEAR) at 11:30 AM, indicated on (MONTH) 20, (YEAR), two certified nursing assistants (CNA) witnessed Resident 2 was hit multiple times by her mother during an argument between Resident 2 and her mother. Resident 2 was also hit on the face that caused her left eyebrow wound to reopen and bleed. During an observation and concurrent interview on (MONTH) 30, (YEAR) at 11:45 AM of Resident 2, she was in in bed and did not want to talk about the incident. An interview with the Licensed Vocational Nurse 1 (LVN 1) on (MONTH) 2, (YEAR) at 1:00 PM she stated that Resident 2 had a prearranged doctor's appointment that day . Resident 2's mother was the one who was to drive and accompany her to Resident 2's appointment in Resident 2's mother's private vehicle. LVN 1 stated that she allowed the mother to drive her daughter (Resident 2) to her doctor's appointment on the day the incident occurred. An interview with the Director of Social Services (DSS) on (MONTH) 2, (YEAR) at 2:00 PM, she stated that she was not able to complete her investigation about the incident. DSS stated that Adult Protective Services (APS) and police were not notified of the incident. An interview with the Administrator on (MONTH) 2, (YEAR) at 3:00 PM, he stated he was not able to report the unusual occurrence to California Department of Public Health. During an interview with CNA 5 on (MONTH) 4, (YEAR), at 11:30 AM, she stated that she witnessed the argument between Resident 2 and her mother. CNA 5 stated that she saw the mother hit Resident 2 on her lower extremities, abdomen, and the left side of her face. Resident 2 had a swollen wound on the left eyebrow and the wound bled after being hit by her mother on the left side of her face. The Facility's policy and procedures titled, Abuse Prevention and Prohibition Program, undated, indicated under Investigation, a. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, or injuries of an unknown source . I, the Facility will report known or suspected instances of physical abuse, including sexual abuse, to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations .

Based on observation, interview, and record review, the facility failed to ensure identification and reporting of a suspicion of crime to appropriate agency for three of 27 sampled residents (Resident 211, Resident 56, and Resident 2) in a universe of 92 residents when: 1. The facility failed to report verbal abuse of the physician to Resident 211. 2. Resident 56 felt staff were retaliating against him, after he had filed a complaint with the California Department of Public Health (CDPH). 3. The family member struck Resident 2 multiple times as witnessed by facility staff. These failures resulted in physical and mental abuse of the residents. Findings: 1. During a recertification survey of the facility, on (MONTH) 30, (YEAR) at 8:00 AM, an observation of Resident 211 was made. Resident 211 was awake inside his room and in bed, covered with a personal blanket. Resident 211's breakfast tray remained untouched. During an interview with Resident 211, on (MONTH) 30, (YEAR) at 8:05 AM, he stated, I want you to have time and sit down because I have been thinking about this for so many weeks now. I feel not being safe here and threatened. Nobody protects me here. Resident 211 stated that a month ago while in the social services office, when the doctor called him an f****** (expletive) idiot and was witnessed by the social workers inside the office. Resident 211 also stated Doctor (name of the physician) was standing and I was sitting in a wheelchair when he pointed his finger in my face and told me that I am a 'f****** (expletive) idiot'. I felt so mad and so helpless because I was in a wheelchair. I felt so small. Resident 211 was tearful and kept on wiping his eyes during the conversation. He further stated, Every time that he is in the facility, I kept my distance. If I'm on the floor, I go back to my room and close my curtains so he won't see me and I won't see him. During an interview with the Director of Nursing (DON), on (MONTH) 30, (YEAR) at 2:49 PM, the DON stated that she was not aware of the incident and stated, Maybe the social workers know. Sometimes they will put my name on the note that I know, but I don't know. During an interview with the Social Worker (SW 1), on (MONTH) 1, (YEAR) at 6:40 AM she stated The incident happened a month ago, when they had an argument. The documented incident was given to the Administrator (ADM). During an interview with the Social Worker Assistant (SWA 1), on (MONTH) 2, (YEAR) at 11:08 AM, she stated I witnessed what had happened, and if someone told me that I am acting like an idiot, I will feel offended because that is not acceptable and not appropriate to say to someone, not at all. During an interview with the SW 1, on (MONTH) 2, (YEAR) at 11:02 AM, she stated Doctor (name of the physician) and the Resident (Resident 211) were bickering each other. The SW also stated that the ADM must be informed if there is an incident of abuse and the ADM is the one who must report to the state (California Department of Public Health). During an interview with ADM, on (MONTH) 2, (YEAR) at 3:09 PM, he stated the incident was reported to him and was not reported to CDPH office. The ADM stated Doctor (name of the physician) did not say 'you are an idiot', he said 'you are acting like an idiot'. And I do not considered it as verbal abuse. That is why I did not report it. During an interview with SWA 1, on (MONTH) 4, (YEAR) at 9:18 AM, she stated I was typing on my computer when the Doctor (name of the physician) and (name of SW 1) came in the office with the Resident (Resident 211) to the doorway in a wheelchair. The SWA 1 further stated Doctor (name of the physician) said to the Resident (Resident 211) 'You are acting like an idiot'. Then they (physician and Resident 211) left the office and went to the nurse station. The SWA 1 was asked about what she did after witnessing the incident, she further stated I kept on what I was doing. During an interview with SW 2, on (MONTH) 4, (YEAR) at 9:33 AM, she stated I was in the DSD (Director of Staff Development) office when I heard the resident (Resident 211) arguing with someone. When the SW 2 was asked if she saw the situation she further stated I did not look. I stayed in the DSD office. During a record review of Resident 211's medical records, on (MONTH) 4, (YEAR) at 10:43 AM, there was no documented follow up evidence related to Resident 211's encounter with the physician. During a record review of facility document titled, Investigative Interview Transcript - Employee signed by SW 1, dated (MONTH) 13, (YEAR), it indicated that Resident 211 and the physician were bickering (arguing) back and forth, It also indicated that the Resident 211 was given a new physician. During a record review of facility document titled, Investigative Interview Transcript - Employee signed by SWA 1, dated (MONTH) 13, (YEAR), it indicated that SWA 1 did hear the physician stated You (Resident 211) are acting like an idiot. During a record review of Resident 211's medical record, Resident 211 was admitted to the facility on (MONTH) 23, (YEAR) with admitting [DIAGNOSES REDACTED]. A review of facility document titled Resident Admission Form, dated (MONTH) 23, (YEAR) at 2:45 PM, indicated a behavioral/cognitive assessment of being alert and cooperative. A review of Minimum Data System (MDS- assessment tool for Resident), dated (MONTH) 20, (YEAR), the Section C-Cognitive Patterns in BIMS (Brief Interview for Mental Status-test given by medical professionals that helps determine a patient's cognitive understanding) is 15. The Resident has capacity to make his needs known. During a record review of Resident 211's medical records, there was no documented evidence related to Resident 211's encounter with the physician that was reported. A review of facility document titled, Job Descriptions-Social Service Designee, indicated Administrative Functions: Work with emotional problems including assisting the resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care. A review of facility document titled, Job Descriptions-Director of Nursing Services, indicated Resident Rights: Report and investigate all allegations of resident abuse and/or misappropriation of resident property. A review of facility policy and procedure titled, Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of [REDACTED]. Abuse includes, but is not limited to physical, mental, verbal, sexual, or financial abuse or misappropriation of resident property. The facility maintains zero tolerance to any abuse to residents from anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. A review of facility policy and procedure titled, Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of [REDACTED]. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, or use of offensive language. And also indicated on page 7 of 7 Reporting: The Administrator in coordination with Compliance Officer with either verify or report all allegations of abuse or neglect in accordance with the state and federal regulations including but not limited to the Elder Justice Act. A review of the facility policy and procedure titled, Resident Rights dated (MONTH) (YEAR), indicated Policy: It is the policy of this facility to treat each resident with respect and dignity and care for each resident that recognized his or her individually. A review of facility document titled, Resident Bill of Rights, indicated The Right: 10. To be treated with consideration, respect, dignity and individuality, including privacy in treatment and in the care of personal needs. 2. During an observation and interview on (MONTH) 3, (YEAR), at 8:10 AM, Resident 56 appeared to be anxious and asked this Registered Nurse (RN) if he could ask some questions regarding his rights in the facility. Resident 56 asked if he was able to eat in a dining room. He further stated, I was eating in this (pointed to the dining room behind him which is used for residents who need assistance with eating) dining room and (Name) started yelling at me across the room and told me I could not eat in the dining room. (Name) told me that I was and that I was being disruptive to the rest of the staff and the other residents and I needed to leave. Resident 56 further stated that there were two other staff who saw what happened. As the interview continued, Resident 56 continued to say over and over, Why can't I eat in the dining room. He also stated, What did I do wrong, what did I do wrong . Resident 56 stated, I said something to CNA 2 who was sitting next to me that wasn't in nice that (Name) got the promotion. CNA 2, said something like yes and went back to feeding her resident. This is when (Name) (Restorative Nursing Assistant, RNA, an extended role for a certified nursing assistant, that can assist Residents with special needs) starting yelling at me, saying I was gossiping and interrupting the CNA from doing her job. Resident 56 stated, That the RNA walked out of the dining room and everything was quite for a while. Then the RNA returned and started yelling even more, she told me to quit talking to the staff. Resident 56 stated over and over, What did I do wrong? What did I do wrong? Resident further stated that (Name) came in and told me to quiet down and told the RNA to leave. (Name) and the Charge Nurse (CN). The CN and I talked and I told her that I was never going to eat in one of the dining rooms again that I was only going to stay in my room and eat in there from now on, because they made me feel as I was doing something wrong. Resident 56 continued with interview, I was called in to the Social Services Director (SSD) after this happened. The SSD told me that I had been disruptive in the dining room today and then she told me that I had the right to eat in any dining room I want, but that one is for the other residents who need more attention when they are eating. She (SSD) told me that as long as I don't disturb others then I can eat in the room. Resident 56 stated felt as if he was being treated like a child who was being scolded and disrespected. A review of Resident 56's face sheet (document that includes demographics and medical information), indicated that Resident 56 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. During an interview on (MONTH) 3, (YEAR), at 8:45 AM with the RNA, the RNA stated Resident 56 was gossiping with another staff member at the table he was sitting, I told him to stop talking the CNA who is supposed to be feeding another resident. I also told the CNA to stop talking to the resident and to quit gossiping about other staff members. The RNA indicated that she was at one table and Resident 56 was at another table (approximately 20 feet apart), the RNA stated That he got very upset, I tried to explain to him why he shouldn't be here, but he continued to engage. I got up and left the dining room and went to report it to the SSD. I came back into the dining room and Resident 56 was talking to another resident who wanted to ask me questions about what had happened. During an interview on (MONTH) 3, (YEAR), at 8:55 AM with the SSD, the SSD stated the RNA came into tell me that Res 56 was being disruptive in the dining room and talking to staff and gossiping. She stated, The resident came in to talk with me and we talked about the dining room rules that he can eat in either dining room as long as he is not disruptive to others. I also counseled him on appropriate behaviors. During an interview on (MONTH) 3, (YEAR), at 9:00 AM with CNA 1, the CNA stated, I was assisting in the dining room with resident feeding. Resident 56 said something like how nice it was that another staff member got a promotion, I said yes and went back to helping with my resident. Then the RNA started yelling at me not to talk to Resident 56 about personnel issues. She further stated, The RNA was acting rude and disrespectful to the both of us, yelling across the room. She was creating a scene and a conflict when there was nothing going on. I was assisting my resident and listening to Resident 56. The RNA should never have done that, she should have handled the situation better. During an interview on (MONTH) 3, (YEAR), at 11:30 AM with Charge Nurse (CN), the CN stated I heard raised voices in the dining room telling a resident that he can't be in the room, I came in a separated them and told the RNA to go talk to her supervisor. I talked to Resident 56 and told him that he should talk to the Administrator or a state surveyor if he had any other issues. The CN further stated, From what I saw the resident was not being disruptive. When the RNA returned to the dining room, she started up at it again, she was yelling and the pitch of her voice was rising, of course when then Resident 56's voice was also getting louder. I heard the RNA tell the resident that he could not eat in the dining room and talk about other people, she was quite upset. Resident 56 was done and he left the room. The CN confirmed that she had not reported the incident with anyone. During an interview on (MONTH) 3, (YEAR), at 11:45 with the Director of Staff Development (DSD) related to the incident in the dining room, the DSD stated What incident? During an observation and interview on (MONTH) 3, (YEAR), at 11:55 AM with Resident 56, the Resident stated What did I do wrong? I am so upset I have turned off my phone, I don't want to talk to my Mom or my family, and I don't want to take this out on them. Resident appears anxious and fidgeting in his bed with the privacy curtain pulled sitting in the dark. Resident 56 continues, I always try to do the right thing, I don't understand what I did wrong. I'm never going into the dining rooms again, I felt so humiliated and felt like I was a child being scolded. He further went on to say that he overheard staff members talking saying that I'm nothing but a trouble maker after I talked to you (CDPH - RN). Resident 56 did not want to give anymore names, what else will happen. I still don't know why they did this to me.' During an interview on (MONTH) 3, (YEAR), 12:20 PM with the facility contracted Psychologist (PhD), the PhD stated I'm glad you came to me when you did, Resident 56 is very hurt, anxious, and agitated. He is verbalizing how he felt disrespected by the staff in the dining room this morning, and that the staff were yelling at him, scolding him like a child. The PhD further states Resident 56 is the most easy going resident in this building, he is mellow, he is a gentleman, and he is always trying to the right thing to fit it. A review of the PhD note dated (MONTH) 3, (YEAR), indicted Provided session in response to an incident occurring in the large dining room. Resident had been reprimanded for discussing personal business with staff members and being disruptive. He verbalized feeling humiliated and disrespected as though he were a child being scolded by his Mom. He further noted that Resident 56 was uncertain as to exactly he did wrong. I assured Resident 56 that he had done nothing wrong. During a review of Nursing Notes for (MONTH) 3, (YEAR), nothing was documented regarding the incident. During a review of Care Plans Resident 56 is care planned for anxiety and depression. The last review of the care plan was (MONTH) 3, (YEAR), with no changes noted. During an interview on (MONTH) 4, (YEAR), at 9:15 AM with CNA 2, CNA 2 stated Resident 56 is a very friendly guy, he is easy to get along with, is very independent in his care. CNA 2 continued to say that he can be outspoken when he needs to be, if it has something to do with his care. His one thing is that he does not like to be woken up in the morning, if he is sleeping, he wants to be left alone. During an interview and concurrent record review on (MONTH) 4, (YEAR), at 9:53 AM with the SSD, the SSD stated, Resident 56 does not have any behavior issues, he is always so easy going, so when the RNA came and told me about the incident I thought it was unusual so that's why I called him in. During a review of the notes you wrote The resident was counseled on appropriate behavior. The SSD indicated that she had not investigated the situation prior to talking to the Resident, that she had just gone on what the RNA said. She further stated that looking back at it, the RNA, was talking a lot, saying things that I could not make out, she was talking so fast, she was yelling and was irritated. The SSD confirmed that she had not reported the incident to anyone. During an interview and concurrent record review with the Director of Nursing (DON) on (MONTH) 4, (YEAR), at 10:20 AM, the DON stated The incident yesterday (May 3, (YEAR)) was not reported to me. The DON described the facility policy on an allegation of abuse, she stated that it should have been reported, the physician should have been notified, a change of condition should have been completed and a care plan developed related to the psychological aspect of the incident. The DON confirmed that the incident was not reported to her, that there was no documentation that the physician was notified, that no change or condition or care plans were completed. During an observation and interview on (MONTH) 5, (YEAR) at 10:40 AM, Resident 56 approached a Health Facilities Evaluator Nurse (HFEN), stating There was another incident last night (May 4, (YEAR)) between him and a Licensed Vocational Nurse 5 (LVN). He stated LVN 5 told him he was verbally abusing CNA 4. Resident 56 stated that he felt the staff were targeting himfor his complaint to the state earlier, he appeared nervous and anxious about what was going to happen to him. Resident 56 stated I feel that my previous complaint to the state had backfired on me. He stated It all started when he lost his vape (electronic cigarette) and he accused CNA 4 of taking it. Resident 56 further stated LVN 5 approached him and was Verbally chastising him, he stated that when LVN 5 talked to him, he was told he was being verbally abusive to the staff. During an interview on (MONTH) 5, (YEAR), at 2:00 PM the, LVN 5 stated I was approached by CNA 4 and told that Resident 56 was accusing him of stealing his vape. LVN 5 stated she reported the incident to the Administrator (ADM) about the incident. The ADM sent a text which stated, They (the residents) have to know with state in the building, if they keep complaining, it could force us to move them elsewhere. LVN 5 stated that when she talked to Resident 56 about this, she talked to him in a nice way as she explained the text to the resident, but that Resident 56 was defensive, angry and felt he was being harassed. During a review of the Nurses Notes indicated, Resident 56 was being monitored as per the Corrected Action Plan for any negative impact to the psychosocial well-being of the resident for 72 hours. The notes did not indicate that another incident took place on (MONTH) 4, (YEAR). A review of Resident 56's Short Term Care Plan entitled 'Risk of psychological distress after verbal altercation with staff members was initiated on (MONTH) 5, (YEAR), two days after the IJ was called. A review of the Investigation Report for the allegation of abuse indicates I, the ADM was notified late morning by the surveyor of an allegation of verbal abuse from staff member (LVN) and resident at approximately 10:20 PM on (MONTH) 4, (YEAR). According to the resident, the Resident, LVN talked to me about speaking inappropriately to staff members. She (LVN) went on to say that if I was not happy here that the facility could help me find placement elsewhere. According to the LVN, she was professional, calm, and non-condescending when she spoke to the resident. She reiterated what she told him and said he was fine. I spoke with the resident in the afternoon on (MONTH) 5, (YEAR) and explained to him where the LVN's counsel came from. But I made it clear to him that this was his home and we would like it very much if he would stay and not feel that he needed to find another place to live. He agreed to hang in there for me and to personally contact me if any further issues. LVN was suspended pending investigation. A review of the facility policy and procedure entitled, Abuse Prevention and Prohibition Program, undated, indicates Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents , and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property in accordance with federal and state requirements. Policy 1. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. 3. A review of the clinical record of Resident 2 on (MONTH) 30, (YEAR) at 11:00 AM indicated she was admitted to the facility on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. A review of the clinical record of Resident 2 on (MONTH) 30, (YEAR) at 11:30 AM, indicated on (MONTH) 20, (YEAR), two certified nursing assistants (CNA) witnessed Resident 2 was hit multiple times by her mother during an argument between Resident 2 and her mother. Resident 2 was also hit on the face that caused her left eyebrow wound to reopen and bleed. During an observation and concurrent interview on (MONTH) 30, (YEAR) at 11:45 AM of Resident 2, she was in in bed and did not want to talk about the incident. An interview with the Licensed Vocational Nurse 1 (LVN 1) on (MONTH) 2, (YEAR) at 1:00 PM she stated that Resident 2 had a prearranged doctor's appointment that day. Resident 2's mother was the one who was to drive and accompany her to Resident 2's appointment in Resident 2's mother's private vehicle. LVN 1 stated that she allowed the mother to drive her daughter (Resident 2) to her doctor's appointment on the day the incident occurred. An interview with the Director of Social Services (DSS) on (MONTH) 2, (YEAR) at 2:00 PM, she stated that she was not able to complete her investigation about the incident. DSS stated that Adult Protective Services (APS) and police were not notified of the incident. An interview with the Administrator on (MONTH) 2, (YEAR) at 3:00 PM, he stated he was not able to report the unusual occurrence to California Department of Public Health. The Facility's policy and procedures titled Abuse Prevention and Prohibition Program, undated, indicated under Investigation, a. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, or injuries of an unknown source . I. the Facility will report known or suspected instances of physical abuse, including sexual abuse, to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations .

Based on interview, and record review, the facility failed to ensure that a certified nurses assistant (CNA 1) used the walk away protocol (leave and return) when Resident A engaged CNA 1 in a verbal altercation. This failure resulted in CNA 1 verbally abusing one of three sampled residents (Resident A) when he yelled and cursed at Resident A, even after the licensed staff had told him to walk away. Finding: An unannounced visit was made to the facility on [DATE], to investigate an entity reported incident related to resident abuse. Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview with a license vocational nurse (LVN 1) on November 18, 2015 at 11:00 AM, she stated she was standing in the 400 hall with her supervisor and heard yelling at the end of the hall. LVN 1 went to investigate the yelling and found CNA 1 yelling and cursing at Resident A. LVN 1 instructed CNA 1 to leave the room and use the, walk away policy. CNA 1 disregarded the instruction and continued to argue. Once CNA 1 left the room, CNA 1 returned a second time, and tried to charge(approach quickly) the resident and was stopped by LVN 1. While LVN 1 was leaving the room after checking on the Resident A, CNA 1 attempted to come back to Resident A's room a third time, calling the resident a F A H . CNA 1 was then assisted off the hall by LVN 1 and reported to the Registered Nurse (RN) supervisor. A review of the facility's policy and procedure titled, Walk-Away,undated, indicated, It is the policy of this Facility that any staff member who becomes frustrated when assisting a resident, visitor or other staff member must walk away from the situation, absent an emergency, and request assistance so as to prevent a resident from being subject to inappropriate conduct which includes but is not limited to, verbal, mental, sexual or physical abuse, corporal punishment, involuntary seclusion or misappropriation of a resident's money or other property. During a review of CNA 2's written declaration regarding the verbal altercation between Resident A and CNA 1, CNA 2 indicated she returned from her break and heard CNA 1 and Resident A yelling at each other. LVN 1 was trying to calm CNA 1 down and to have him walk away. CNA 1 would not leave it alone, he kept coming back to yell and curse at Resident A. A review of CNA 1's file indicated CNA 1 was suspended immediately, then terminated on October 16, 2015, after the investigation, and was not available for interview. During a review of the facility policy and procedure titled Abuse Prevention & Elder Justice Program dated 2013, indicated that .Each resident has the right to be free from all forms of abuse. This facility works to ensure that its residents are not subject to abuse by anyone, including facility staff, other residents, consultants or volunteers or other agencies serving the residents.

Based on observation, interview, and record review, the facility failed to provide supervision to ensure the safety of one out of 18 sampled residents (Resident 12), who had a history of [REDACTED]. This failure resulted in Resident 12 eloping from the facility through an unsecured front door and sustaining a fall from his wheelchair which resulted in serious injuries including a fractured (broken) neck and facial fractures. Findings: A review of Resident 12's updated Clinical [DIAGNOSES REDACTED]. cells; mental decline), dementia (brain disease that causes memory disorders, personality changes, and impaired reasoning), seizure disorder (uncontrolled electrical activity in the brain), and a history of falls. Resident 12's care plan titled, Potential for Falls, dated March 24, 2015, indicated, Problem impaired mobility, confusion .reaches forward, seizure activity, attempts to stand and/or transfer self, poor safety awareness .increased weakness, poor endurance, history of falls in last month prior to admit, hx (history of) falls in last 2-6 months .Resident Goals .Will be free from significant injury x 90 days .Approaches/Action .Frequent visual checks .alarm hallway/unit exterior doors, redirect when verbalizing desire to go elsewhere . Resident 12's medical record indicated Resident 12 had an elopement out of the building on April 20, 2015. Resident 12's care plan titled, Potential for Wandering/Elopement, dated April 20, 2015, indicated, Problem Risk for wandering R/T (related to): .Dementia .Risk for Elopement R/T Elopement out of building on 4/20 (April 20, 2015) D/T (due to) anger issues .Resident Goals .Resident will have no episodes of elopement x 90 days .Approaches/Action .Patient location charting Q15 (every 15 minutes) and prn (as needed); Monitor episodes of elopement attempts; Will D/C (discharge) to locked secured facility when available . Resident 12's Fall Risk Assessment was completed on June 20, 2014 with a score of 16, which indicated a score of 8 or more requires care plan to address risks and prevention . Resident 12's Elopement Risk Assessment was completed on July 3, 2015 with a score of 8, which indicated a score of 7 or more requires an elopement risk care plan . A review of Resident 12's care plan titled, Elopements, dated July 3, 2015, indicated, Risk factors include desire to leave facility .Resident's goal: Resident will have limited to zero elopements and elopement attempts times three months through October 2015 .Interventions .Patient location charting PRN (as needed) .Monitor episodes of elopement attempts . Resident 12's Interdisciplinary Team (IDT) Meeting Note, dated July 6, 2015, indicated, On 7.3.15 (July 3, 2015) @ (at) approx. (approximately) 1700 (5:00 PM), resident was found outside of facility in parking lot by staff. Resident stated he was trying to go to hardware store. Resident w/c (Resident's wheelchair) got stuck in dirt and resident fell out of chair. resident sustained [REDACTED].Resident on frequent visual checks by staff to ensure safety .Will monitor . Resident 12's care plan titled, Potential for Falls, was updated on July 9, 2015 and August 11, 2015, and included information that on both dates an actual fall occurred. There were no new interventions documented after these falls to prevent future falls from occurring. During the initial tour on December 7, 2015 at 4:40 PM, Resident 12 was observed eating in the dining room with his responsible party by his side. Resident 12 was observed to have a left eye injury with red and purple discoloration around the outer edges of his eye, with bandage strips on the left temple area. During a concurrent interview with Resident 12's responsible party, she stated that Resident 12 fell outside this morning (December 7, 2015), while he was in his wheelchair and hit his head. During a concurrent interview with Resident 12, when asked what happened in regard to the fall he said, I do not remember what happened. Resident 12's medical record indicated the Resident eloped out of the facility on December 7, 2015 at 7:40 AM, and his wheelchair flipped over which resulted in an injury to the left temple, eye, cheek, knee, and wrist. Resident 12 was on Shadow Checks (staff do visual checks every 15 minutes and document the location of a resident) for 24 hours following the incident. During an interview with a Registered Nurse (RN 1), on December 7, 2015 at 4:45 PM, she stated Resident 12 has Dementia (a brain disease that causes memory disorders, personality changes, and impaired reasoning) and wanders. RN 1 stated a passerby found Resident 12 and brought him back into the facility. RN 1 stated the facility's protocol following a head injury was to do a head-to-toe assessment, neurological checks (assessment of sensory and motor responses to determine if the nervous system is impaired), frequent visual checks (knowing the resident's whereabouts), look for a change in mentation (mental status), to notify the doctor and the family, and the resident would be monitored for 24 hours. Resident 12's care plan titled, Potential for Falls and Potential for Wandering/Elopement, were updated on December 7, 2015 as follows: a. Resident 12's Interventions for Elopement: Redirect (Resident 12) when verbalizing desire to go elsewhere. b. Resident 12's Interventions for Falls: Alarm hallway/unit exterior doors. During an interview with the Administrator, on December 9, 2015 at 6:25 AM, she stated the doors are locked and alarmed from dusk to dawn and the staff were in-serviced on December 7, 2015, about securing the facility following Resident 12 eloping because the alarms were not set. When asked if the Administrator had a policy on securing the facility, she stated, We do not have a policy, we have protocols. She said the protocols were not written. When asked who monitors the front door entrance, the Administrator stated the facility had cameras, however several of the cameras did not work because the facility was being re-wired. Resident 12's medical record indicated Resident 12 eloped out of the facility again on December 9, 2015 at 9:30 PM, when his wheelchair landed on top of him in the bushes, which resulted in swelling of his eye and bleeding from his head. Resident 12 was transferred to the general acute care hospital where he was admitted to the intensive care unit due to the injuries sustained in this fall. Resident 12's CT Scan Report (a x-ray test in which a computer takes a cross-section of a person's anatomy) dated December 9, 2015, indicated .Acute depressed right orbit floor (the bones of the eye socket) fracture into the maxillary sinus (broken facial bones) .Acute type III odontoid fracture of the cervical spine (broken neck bone) . Resident 12's care plan titled, Potential for Falls, initiated on March 24, 2015, was updated on December 9, 2015 to include Resident 12 having an actual fall. Resident 12's care plans titled, Potential Falls and Elopements were updated to include the following intervention: Frequent checks. The frequency and types of checks to be done were not specified. During an interview with the Administrator on December 10, 2015 at 4:30 PM, she stated that Resident 12 fell again last night (December 9, 2015). During an interview with Resident 12's responsible party (RP) on December 11, 2015 at 9:00 AM, she stated Resident 12 was unable to push the doors open by himself. The RP further stated that she got a call from a Registered Nurse (RN 3) on December 9, 2015, and was informed a pizza delivery guy came and had to let Resident 12 out of the front door. The RP said that she had received a call from a different nurse earlier that day (December 9, 2015), informing her that the main entrance door was going to be locked at dusk every night. The RP stated Resident 12 was found in the front driveway near the church with the wheelchair on top of him by a passerby and that he was in the Intensive Care Unit (of an acute care hospital) with a fractured (broken) neck and facial fractures. During an interview with a Licensed Vocational Nurse (LVN 3), on December 11, 2015 at 11:32 AM, she stated that Resident 12 wanders at times. LVN 3 stated CNAs are told to check every 15 minutes if he is on shadow checks, and every 30 minutes to monitor where he was in the building. LVN 3 stated she could not recall if he was on shadow checks at the time of his elopement on December 9, 2015. She said when a resident was found to be missing the facility would call a code over the loud speaker and check everywhere to locate the resident. During an interview with the DON on December 11, 2015 at 12:30 PM, she stated she had shadow check documentation for December 7, 2015. The DON further stated that nurse's document visual checks every shift and shadow checks are done for 24 hours (following an incident), then they stop. During an interview with the Registered Nurse Supervisor (RNS), on December 11, 2015 at 3:00 PM, she stated the facility did not have a list of residents who are at risk for elopement. During an interview with a Licensed Vocational Nurse (LVN 4), on December 11, 2015 at 4:00 PM, she stated Resident 12 has been on shadow watches (checks) quite a few times because he threatened to leave the facility. LVN 4 further said usually the CNAs document on the shadow check sheet and a licensed nurse does a note during the shift. LVN 4 stated she would look for the resident every 15 minutes and make sure he (Resident 12) was safe when he was on shadow checks. During an interview with a Registered Nurse (RN 3), on December 11, 2015 at 5:00 PM, she stated on the night of December 9, 2015, she was at the nurse's station when a gentleman came up to her saying there was a man in a wheelchair in the front driveway. RN 3 stated she did not know if the gentleman was a pizza delivery person or visitor and was uncertain how he got into the facility. RN 3 further stated the doors were locked and the only door that the gentleman could come through was located in the 300 hall. The nursing staff had a buzzer they would push that unlocked the door to allow entry. RN 3 stated she asked a Certified Nurse Assistant (CNA 6) to help and followed the gentleman, who reported a resident was outside, to the main entrance door. RN 3 stated when she walked up to the main entrance door, the banner (a yellow banner to discourage people from exiting the front doorway after dusk) was on the ground. RN 3 said she exited the front door and saw Resident 12 lying toward the curb at the end of the driveway with his wheelchair on top of him. RN 3 said the wheelchair was taken off of Resident 12 and 911 was called from CNA 6's cell phone. RN 3 stated the facility was called and a LVN and CNAs came outside to assist. RN 3 further said that she was aware of the fall Resident 12 had on December 7, 2015, and that she believed shadow checks were over. A review of the facility's policy and procedure titled, Elopement Prevention and Management, dated July 2013, indicated, It is the policy of this facility to minimize the risk of elopement and take action to locate a missing resident .Residents who are at risk for elopement (those residents with a clear history of repeated elopements) will have an appropriate plan of care developed to address the risk .The licensed nurse shall document all appropriate information in the clinical record before he/she ends his/her shift pursuant to the general documentation policy. All charting and reports should be complete before leaving .

Based on staff interview and record review, the facility failed to ensure that interventions were developed to prevent falls from the wheelchair for one of three sampled residents (Resident 1). This failure resulted in Resident 1 falling from the wheelchair on September 3, 2015 and sustaining a hip fracture. Resident 1 required surgical intervention and was admitted to the acute care hospital for five days. Finding: During a review of Resident 1's clinical record documented that Resident 1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's admission Resident Assessment Instrument (a tool used to assess a resident from head to toe) documented that Resident 1 was alert with confusion and could sometimes make her needs known to others. Under mobility the RAI documented that Resident 1 was a one person assist for transfers and assistance. During an interview on September 23, 2015 at 9:30 AM with the complainant, the complainant stated that Resident 1 was transferred from the facility and admitted to the acute care hospital on September 6, 2015. The complainant stated that Resident 1 fell from the wheelchair and sustained a fractured hip (broken bone in hip). During an interview on September 23, 2015 at 11:30 AM with Certified Nurses Assistant 1 (CNA 1), CNA 1 stated that Resident 1 was alert but had periods of being confused. CNA 1 stated that Resident 1 was able to propel herself with her feet while in the wheelchair. CNA 1 stated that Resident 1 could stand but could not walk well and needed close supervision and assistance. CNA 1 stated that Resident 1 had to be reminded sometimes not to get up from the wheelchair or bed on her own. During an interview with CNA 2 on September 23, 2015 at 11:45 AM, CNA 2 stated that on September 3, 2015 at approximately 6:30 PM, Resident 1 was in the dining room sitting in her wheelchair. CNA 1 stated that Resident 1 had a verbal discussion with another resident and the other resident began to cry. CNA 1 stated that she was standing next to Resident 1 and left Resident 1's side to assist the other resident. CNA 1 stated that when she went to assist the other resident, Resident 1 got up from her wheel chair and fell . CNA 1 stated that Resident 1 complained of hip pain. During a review of Resident 1's clinical record documented that Resident 1 had three falls from the wheelchair between March 2015 and September 2015; 1. March 25, 2015: Resident 1 was attempting to get up from her wheelchair to transfer to the bed and fell . No evidence of assessment or if any injuries were sustained. Unwitnessed fall. The ADON confirmed there was no evidence of an assessment in Resident 1's clinical record. 2. August 7, 2015: Resident 1 wheeled herself to the end of the hallway and was found on the floor next to her wheelchair. Resident 1 complained of shoulder pain. Unwitnessed fall. 3. September 3, 2015: Resident 1 was in the wheelchair in the dining room, stood up and fell . Resident 1 complained of left hip pain. witnessed fall. During an interview with Licensed Vocational Nurse (LVN 1) on September 23, 2015 at 12:25 PM, LVN 1 stated that on September 3, 2015 at approximately 6:30 PM, CNA 2 reported that Resident 1 fell from the wheelchair. LVN 1 stated that Resident 1 was assessed to have left hip pain. LVN 1 stated that On September 9, 2015 Resident 1 had low saturation levels (oxygen in the blood ) and altered level of consciousness (sleepy and hard to wake up ) and was transferred to the acute care hospital. During a review of the acute care hospital History and Physical dated September 6, 2015 documented that Resident 1's x-ray on admission indicated a left hip fracture.Resident 1 had surgery for [REDACTED]. Resident 1 was discharged from the acute care hospital on September 13, 2015. Resident 1 stayed a total of five days at the acute care hospital. During a review of Resident 1's clinical record showed no evidence that the facility developed interventions to prevent Resident 1 from falling from the wheelchair on March 25, 2015 when Resident 1 attempted to transfer from the wheelchair to the bed. There was no evidence in the clinical record that the facility developed interventions to prevent Resident 1 from falling from the wheelchair on August 7, 2015 when Resident 1 was found on the floor next to her wheelchair and sustained an injury to her right shoulder. There was no evidence in Resident 1's clinical record that the facility identified on August 7, 2015 that Resident 1 was attempting to get out of the wheelchair and was at risk for falling. During an interview on September 23, 2015 at 12:10 PM with the Assistant Director of Nurses (ADON), the ADON stated that when residents sustained a fall, an Interdisciplinary Team Meeting (IDT) was conducted to assess the resident and come up with ways to prevent the resident from falling. The ADON confirmed that there were no interventions developed on March 25, 2015 to prevent Resident 1 from falling from the wheelchair. The ADON confirmed that there were no interventions developed on August 7, 2015 to prevent Resident 1 from falling from the wheelchair. During an interview on September 23, 2015 at 12:50 PM, the ADON stated that the facility should have developed interventions for Resident 1 in March, and in August of 2015. The ADON stated that the facility's policy for falls are in place to ensure residents are not at risk for falling. During a review of the facility's policy and procedure titled fall Management Program updated July 2013 documented Individualized care plans would be developed and updated as needed to address risk factors for falls. The Interdisciplinary Team will review all fall reports and will recommend interventions to help reduce further falls.

Based on interview and record review, the facility failed to ensure the protection of one sampled resident (Resident A) from verbal and emotional abuse by a staff member when a Certified Nurses' Aide (CNA 1) yanked the urinal off Resident A's penis while he was in the process of using the urinal. CNA 1 was aggressively yelling at the patient using foul language, slammed the urinal on the bedside table, picked up a toothbrush and snapped it in half. This resulted in Resident A experiencing verbal and emotional abuse and verbalizing fear of CNA 1 if encountered in the community after discharge from the facility. Findings: On April 6, 2015 at 11:00 AM, an unannounced visit was made to the facility to investigate an entity reported incident of emotional and verbal abuse to Resident A. During a review of the facility's investigative summary dated December 30, 2014, the facility indicated,"After investigation, interview with staff and resident, observation and chart review it was determined by the IDT (interdisciplinary team) that the event did occur when (used Resident A's name) stated that (used CNA 1's name)after requesting a toothbrush, came back into resident's room. Resident A was in the process of using the urinal when CNA 1 came back in and stated aggressively, "Aren't you done with that f----ing thing yet?" Yanking it off his (Resident A's) penis. He (CNA 1) then slammed the urinal down on the bedside table, picked up a toothbrush and snapped it in half. CNA 1 then stormed out of the room stating, "I am sick of this f---ing s--t!" During a concurrent interview with the Director of Nursing (DON) on April 6, 2015 at 11:00 AM, the DON stated, "The alleged incident happened on December 23, 2014, but Resident A reported the incident to CNA 2 on December 26, 2014. The allegation was reported to CDPH (California Department of Public Health), Ombudsman, and law enforcement agency who came in and interviewed Resident A. The CNA was initially suspended and then terminated after investigation was completed." During an interview with Resident A on April 6, 2015 at 12:00 PM, he stated that he feels better that CNA 1 was already gone. He stated, CNA 1 was rude and treated him bad, talking to him in foul language. Resident A stated, "I was just using the urinal and having problems urinating and CNA1 took away the urinal (while Resident A was using it)." CNA 1 was angry, yelling and threatening. Resident A stated further, "I feel safe here in the facility. I don't know if I get discharged the person (referring to CNA 1) may see me out there. I get discharge in the community I am afraid. What will happen if I see that person (referring to CNA 1) in shopping area." Resident A was asked to whom he reported the incident, he stated to another CNA (CNA 2). During a review on April 6, 2015, of CNA 2's handwritten account of the incident (undated), the note indicated, "I came in on December 25, 2014 and checked my patient (used Resident A's name and room number) and stated he was trying to use a urinal for about an hour. He could not go which is normal. He told me that (CNA 1's name) a PM shift CNA tore away the urinal from his penis, told the resident to, "give me that f__ng s__t) pulling the urinal away from (Resident A's name) penis. (Used Resident A's name) of course got upset and told him (CNA 1) what he did that for?" CNA 1 told Resident A to," shut up or he will punch him in the mouth. I was concerned about this behavior and reported it right away and I also confirmed with (CNA 1's name) what resident stated and (CNA 1's name) admitted he did it because he was tired of waiting on the resident to finish peeing in the urinal." A review of Resident A's clinical record conducted on April 6, 2015, revealed Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident A's history and physical completed by the physician on December 21, 2014, indicated that Resident A was capable of making decisions. A phone interview with CNA 2 was conducted on April 8, 2015 at 9:50 AM. CNA 2 stated that Resident A reported to him that CNA 1,"...doesn't do much. He is lazy. Resident A stated, (used CNA 1's name) came in that day pissed off....ripped the urinal off Resident A's penis. CNA 2 stated he, "... came up to CNA 1 and asked him if the incident reported by Resident A was true, and CNA 1 admitted he did it." CNA 1 said, "He (Resident A) is pissing me off!" During review of documentation in CNA 1's employee file, the documentation indicated CNA 1 had a "Formal Notice of Suspension," dated December 26, 2014 listing the reason as "Alleged Abuse." CNA 1 was suspended from work on December 26, 2014 through December 29, 2014. On December 30, 2014, an "Employment Termination Notice," for CNA 1 was issued for "Inappropriate treatment of [REDACTED]." A copy of an e-mail titled, "Alleged Abuse," was sent by the Director of Staff Development (DSD) to the Certified Nursing Assistant (CNA) Board informing of them of (CNA 1's name ) being investigated for alleged abuse. During a review of the facility's policy and procedure titled, "Abuse Prevention & Elder Justice Program," version 07.2013, the policy indicated: "Each resident has the right to be free from all forms of abuse (verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusions, mistreatment, neglect, and misappropriation of money or property). This facility works to ensure that its residents are not subject to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. All forms of abuse are strictly prohibited by this facility." The policy defined, "physical abuse as hitting, slapping, pinching, kicking, and includes controlling behavior through corporal punishment."

Based on interview and record review, the facility failed to ensure all residents were free from physical abuse, when a certified nursing assistant (CNA 1) allegedly pinched and twisted Resident 1's nipples on several occasions, and would not stop when requested to stop by Resident 1. This failure resulted in the Resident 1 being subjected to physical and mental abuse. Findings: During an interview with the Administrator and the Director of Nursing (DON) on March 9, 2015 at 10:00 AM, the Administrator stated, "We called in and reported the Entity Reportied Incident (ERI) as soon as we heard about it. We also called the (used name of law enforcement agency), and they came and interviewed the resident." The Administrator and DON stated, "The resident is unsure the exact date it first happened, and CNA 1 denies everything, but he was suspended right away." During an interview with Resident 1 on March 9, 2015 at 2:00 PM, he stated, "He (CNA 1) penned (poked/ touched his nipples with a pen) and touched my nipples using his fingers over and over. I asked him to stop but he wouldn't stop. It was painful, and he wouldn't stop, and he didn't say anything." Resident 1 stated, "Another time he was sitting in a chair and I was in the wheel chair, and he did it to me. Sometimes I'm lying in bed and he does it too, it's tortuous. He's (CNA 1) been doing it a couple of weeks and I've told everybody. "I feel better now that he's gone. Somebody called the Sheriff's Office and they talked to me too. People like that should not be working here." An interview was conducted with CNA 2, on March 9, 2015 at 12:45 PM, in the presence of the Director of Staff development (DSD). CNA 2 stated, "I saw him (CNA 1) flick the nipples of Resident 1. When CNA 1, and I were passing trays, Resident 1 wanted to go back to bed. I can't remember the exact date, but it was either Saturday or Sunday last week (February 28, 2015 or March 1, 2015), but it was after breakfast in the morning about 9:00 AM. CNA 1 was behind the resident's (Resident 1's) wheel chair and he reached over and flicked Resident 1's nipples, and said to me, 'He (Resident 1) likes it when I play with his nipples. I told CNA 1, You're stupid." The Resident said to me, "You would like it if I played with yours." I said to the Resident 1, "You're gross, don't talk to me like that." Resident 1 said, "You won't be saying that when I'm done." CNA 2 stated, "When we moved the resident to bed, CNA 1 got on one side of the resident, I got on the other side, and using a gait belt we put the resident in bed. I was uncomfortable with what the resident said to me and I left the bedroom." CNA 2 admitted she did not report these abuses she witnessed to a supervisor. During a review of the facility's policy and procedure titled, "Abuse Prevention & Elder Justice Program", version 07.2013, the policy indicated under, "Interfacility Reporting Responsibilities," Section b: "All employees are mandated reporters of abuse,...therefore, if any employee becomes aware of an allegation or suspicion of abuse, or inappropriate conduct and fails to report it as required by law, that employee will be subject to disciplinary action, up to and including termination of employment." During an interview with CNA 1 in the presence of the DSD on March 09, 2015 at 2:45 PM, he stated, "I don't know what he's talking about. When I'm putting him to bed, I'm lying him down and I have only touched his chest and belly. For about two weeks, I was waking him by rubbing him on his belly, and he complained about that, so I then started shaking his chest and he doesn't complain about that. I usually get another CNA to help me move him. Resident 1 tends to be the kind of resident who urinates when you get close to him. I don't know why he made these accusations about me." During a record review on March 9, 2015, of the "Interview/ Debriefing Narrative Records" of CNA 3, dated March 05, 2015, CNA 3 indicated, "I was told by(used Resident 1's name), that (used CNA 1's name) has been pinching him various places and giving him titty twisters (a person pinches then twists another's nipple)." A review of Resident 1's clinical record conducted on March 9, 2015, revealed Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. to carry out daily activities). During a review of CNA 1's employee records on March 9, 2015, the record reflected CNA 1 had attended abuse training on September 25, 2014. The training included all of the following: respectful workplace policy, facility orientation, abuse prevention, handbook, dementia, Alzheimer, code of conduct, code of ethics, residents bill of rights, residents rights, HIPPA, abuse, and neglect. During review of documentation in CNA 1's employee file, the documentation indicated CNA 1 was suspended from work on March 5, 2015 for allegations of abuse, and his employment was terminated on March 9, 2015. During a review of the facility's policy and procedure titled, "Abuse Prevention & Elder Justice Program", version 07.2013, the policy indicated: "Each resident has the right to be free from all forms of abuse (verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusions, mistreatment, neglect, and misappropriation of money or property). This facility works to ensure that its residents are not subject to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians friends, or other individuals. All forms of abuse are strictly prohibited by this facility." The policy defined, "physical abuse as hitting, slapping, pinching, kicking, and includes controlling behavior through corporal punishment."

Based on observation, interview, and record review, the facility failed to assess, notify the doctor, initiate plan of care, and have an ongoing treatment for [REDACTED]. These failures had the potential to cause a further decline in the range of motion of the arms and legs for Resident 14.Findings: During initial tour, on January 12, 2015 at 6:55 PM, Resident 14 was observed to be in a lying position on the geri chair (a reclining chair with wheels). In a concurrent interview with the RN 1 Supervisor (Registered Nurse 1), RN 1 stated, "(Resident 14) is alert to name, with mumbled speech at times and has contractures of the hand and neck. RN 1 stated, (Resident 14) eats meals in the dining hall and is assisted by the RNA (Restorative Nurse Assistant) during meals." During an observation on January 15, 2015 at 11:25 AM, Resident 14 was in bed with eyes closed. In an interview with CNA 1 (certified nurse assistant), she stated, "(Resident 14) gets up on the geri chair for meals, is able to answer questions and has contractures to both her arms and legs." CNA 1 further stated, "RNA comes to do ROM (range of motion) exercises at least twice a day." In an interview with the RNA on January 15, 2015 at 11:40 AM, the RNA stated, "I do not have an order for [REDACTED]. On January 15, 2015 at 11:45 AM, RN 1 assessed Resident 14 to have bilateral contractures of the elbow, wrist, fingers, thigh and hips. The RN 1 supervisor stated, "(Resident 14) also has foot drop (difficulty lifting or holding the front part of the foot)." During an interview with the Director of Rehabilitation Services (DRS), on January 16, 2015 at 9:10 AM, the DRS stated, "In this case it's an oversight, (Resident 14) should have been assessed when hospice was discontinued. The DRS stated, "Screenings are done on all new admissions, for RNA if appropriate." On January 16, 2015 at 10:45 AM, the DON (Director of Nurses) stated, "(Resident 14) should have a range of motion care plan." A review of the clinical record for Resident 14 reflected she was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Record review of a form titled, "(facility name) Resident Admission Form", dated December 9, 2013, reflected under section "musculoskeletal assessment: contracture(s) - location(s) wrist bilat, ankles bilat." (both wrist and both ankles). There was no written documentation to indicate there was a physician's orders [REDACTED]. There was no documentation to show when the foot drop developed. The facility's Policy and Procedure, undated, titled, "Joint Mobility Assessments", indicated, "functional joint mobility assessment will be completed on admission, change of condition, when other full MDS assessment are required. Joint mobility assessments are functional assessments and are completed in accordance with the MDS guidance..."

Based on observations, interviews and record reviews, the facility failed to provide residents with a safe and sanitary environment to help prevent the development and transmission of disease and infection when: 1. The meal trays for one of 18 sampled residents (Resident 9) was left at the bedside, for the resident to consume, for up to 20 hours. The meal trays contained Time and Temperature Controlled for Safety (TCS) foods (foods that require time and temperature control for safety to limit harmful bacteria growth that could result in food borne illness infections if consumed). The facility lacked systems for monitoring the safety of the food left at the bedside. This practice had the likely potential to result in food borne illness for 1 out of 18 sampled residents (Resident 9). 2. Personal items were not labeled in 3 of the resident bathrooms (bathrooms between rooms 206/208, 305/307 and 313/315) affecting a possible 12 residents in a universe of 87. 3. One of 18 sampled residents (Resident 10) did not have clean gauze used for each wound during wound care cleansing. 4. One of 18 sampled residents (Resident 5) had wound care that was not performed per facility policy regarding handwashing/sanitizing performed between glove changes. These failures had the potential for each of the residents to be exposed to cross contamination (an infection introduced by exposure to another source and inadequate sanitizing) and develop an infection which could adversely affect the residents health status. Findings: 1. During an observation on February 20, 2014, at 8:05 AM, in Resident 9's room, a meal tray was noted on his bedside table and the resident was asleep. During a concurrent interview with Licensed Vocational Nurse 3 (LVN 3), she stated that the meal tray was from last night's dinner (February 19, 2014). The tray had been at Resident 9's bedside for approximately 13 hours. It contained steak and brussels sprouts. LVN 3 did not take the dinner tray away, even though it had been at the bedside since the night before. During an observation the same day at 9:00 AM, Certified Nursing Assistant 4 (CNA 4) placed Resident 9's breakfast tray along side his dinner tray. He did not remove the dinner tray that had been in the resident's room since the previous night. The resident remained asleep. During an observation on the same day at 2:00 PM, in Resident 9's room, three meal trays were observed. The dinner tray, observed earlier, was still at the bedside, still with food and had been at the resident's bedside for approximately 20 hours. The breakfast tray from the morning was also at the bedside, still with food and had been at the resident's bedside for approximately 5 hours. The resident's lunch tray had been just delivered and the resident was asleep. During a concurrent interview with LVN 2, she was asked if it was okay to leave the meal trays in the room for so long. She stated that the facility documented in the resident's care plan that the resident refused to let staff remove his meal trays before he was done with them. She stated that the resident requested the trays be left at his bedside so that he could eat them when he was awake. She stated that it was the resident's right to keep the unsafe food at the bedside as long as it was care planned. She did not remove the meal trays that had been left at the bedside since dinner the night before and breakfast. A review of Resident 9's medical record indicated that he was originally admitted to the facility on [DATE], and readmitted on [DATE] after a short stay at the hospital. He was readmitted with [DIAGNOSES REDACTED]. The Minimum Data Set (a comprehensive assessment tool) dated December 12, 2013, indicated that his cognitive skills for daily decision making was independent. It further indicated that he was independent for eating and locomotion (wheeling around the facility). A review of Resident 9's "Nutritional Status Care Plan" dated December 13, 2013, indicated that there was no problem listed that indicated he refused to allow staff to remove his meal trays or concerns regarding the safety of the trays left at the bedside for extended periods of time. There were no resident goals in the care plan that addressed the food safety concerns. The care plan included an entry under the section titled "Approaches/Actions" that stated "Resident refuse to let staff remove tray from previous meals." There were no other approaches or actions listed that directed the staff on how to keep the food safe that was left at Resident 9's bedside and there were no other care plan entries that addressed the safety of leaving the trays at the resident's bedside. Further review of the medical record indicated that there was no documentation in the dietary section notes or in the social services notes regarding the safety of the trays left at Resident 9's bedside. During an interview with the Director of Nursing (DON) on February 20, 2014, at 3:50 PM, he stated that the facility did not have a policy that directed staff regarding how to keep TCS food safe when left at the bedside for an extended period of time. He further stated that the staff had not been educated on how to keep the food safe when it was left at the bedside. He stated that the Registered Dietitian (RD), the facility's food safety expert, had not been consulted regarding the safety of TCS food left at the bedside for extended periods of time. He verified that there was no documentation in the medical record regarding how to keep the food safe when it was left at the bedside. During an interview with Resident 9 on February 20, 2014, at 3:30 PM, he stated that he wanted the trays left at his bedside because he would eat or drink it later when he was awake. During an interview with Social Services Assistant (SSA) on February 20, 2014, at 3:40 PM, she stated that Resident 9 was well known to her because for a long time he had requested that his meal tray be left at the bedside. She stated she didn't know how long the tray could be left at the bedside and stiil be safe. During a telephone interview with the facility's RD on February 25, 2014, at 2:50 PM, she stated that she was not aware that Resident 9 refused to let the staff remove his meal trays from his room. She verified that there was no documentation in Resident 9's medical record regarding how to keep the food safe when it was left at the bedside for long times. She stated that it was a practice that could result in the resident developing a food borne illness from unsafe food consumption. She stated that the trays should not be left at the resident's bedside more than 2 to 3 hours. She stated that she was not informed that Resident 9's trays had been left at the bedside for up to 20 hours. The survey team identified an immediate jeopardy situation on February 21, 2014 at 9:00 AM, as a result of the facility's failure to have a system in place to ensure the safety of the meal trays left at Resident 9's bedside for extended periods of time. This practice had the potential for unsafe food to be consumed by the resident. In addition to the survey team, the Administrator and the DON were present at the time the immediate jeopardy was called. The team accepted a written plan of action for the immediate jeopardy situation on February 21, 2014, at 1:00 PM. The facility implemented a plan of action as follows: Resident 9 was assessed for signs and symptoms of food borne illness, the physician was notified and new orders were implemented to assure the resident was free of food borne illness. The resident's care plan was updated to reflect the changes. A facility policy was developed to address trays left in resident rooms should be no longer than 3 hours. All nursing staff was in the process of being educated on the new policy. The plan included monitoring of the staff adherence to the new policy through the QAPI (Quality Assurance and Performance Improvement) process. On February 21, 2014, between 1:00 and 2:50 PM, multiple nursing staff were interviewed to verify that they understood the new policy. The medical record for Resident 9 was reviewed to verify the care plan was updated and monitoring for signs and symptoms of food borne illness were addressed. The team removed the immediate jeopardy situation on February 21, 2014 at 2:50 PM, based on implementation of the plan in the presence of the Administrator and the DON. 2a. During initial tour on February 18, 2014, at 3:20 PM, the bathroom between rooms [ROOM NUMBERS] contained 2 unlabeled fracture pans (a type of bedpan). The bathroom was between rooms that had 2 residents living in each room for a total of 4 residents that were dependent on that bathroom. During a concurrent interview with LVN 3 (Licensed Vocational Nurse), she observed the fracture pans and stated that they should have each been labeled with the resident's identification. The facility policy and procedure titled, "Labeling of Personal Items," version 07.2013, documented, "All residents' personal belongings should be labeled with the name of the resident to....reduce the potential for cross-contamination through shared items." 2b. During the initial tour on February 18, 2014, at 3:30 PM, in the shared bathroom of adjoining resident rooms' 305/307 (rooms occupied by 4 residents), an observation of 2 toothbrushes without resident identification labels, were placed in an unidentified cup on a shelf above the sink. During a concurrent interview with the RN Supervisor he stated, "I am not sure who they belong to." The facility policy and procedure titled, "Labeling of Personal Items," version 07.2013, documented, "All residents' personal belongings should be labeled with the name of the resident to....reduce the potential for cross-contamination through shared items." 2c. During the initial tour on February 18, 2014 at 3:45 PM, in the shared bathroom of adjoining resident rooms' 313/315 (4 residents), an observation of a specimen hat (container used to collect a urine specimen) was placed on the commode seat, without a resident identification label. During a concurrent interview with the RN Supervisor he stated, "I am not sure who it belongs to. I am not familiar with all the residents." The facility policy and procedure titled, "Labeling of Personal Items," version 07.2013, documented, "All residents' personal belongings should be labeled with the name of the resident to....reduce the potential for cross-contamination through shared items." 3. During an observation of a wound treatment performed on February 19, 2014, at 11:00 AM, LVN 5 used the same 4x4 gauze on all three wounds on Resident 10's right buttock, left buttock and coccyx area. In an interview after the procedure, LVN 5 stated, "I did not know I have to use one at each wound." The facility policy and procedure titled, "Wound Care Suggestions and Documentation," Version: 07.2013, documented, "General Dressing change guidelines: Proper Infection Control shall be maintained at all times when providing wound care to residents. Proper procedure includes: 1. Avoiding cross contamination of multiple wounds by changing gloves between each wound, not using the measuring device for different wounds and washing hands before and after wound care." 4. The clinical record for Resident 5 was reviewed on February 21, 2014. Resident 5 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. During an observation on February 19, 2014, at 3:10 PM, wound care was performed for Resident 5 by the Treatment Nurse (TN). TN removed the old dressing from the gastrostomy site wearing gloves, changed gloves to cleanse the area and applied a topical medication. The TN did not wash his hands and did not use hand sanitizer between the glove changes. During an interview with the TN immediately following the wound care, he stated that he was not sure what the facility policy was regarding hand washing/glove changes, but he would check. The facility policy and procedure titled, "Hand Hygiene Program," version 07.2013, documented that hands were to be washed with soap and water or cleansed with hand sanitizer both before donning gloves and after removing gloves.

Based on interview and record review the facility failed to monitor, and implement appropriate interventions to maintain the hydration (fluid balance) status for 1 of 3 sampled residents (Resident 1). This failure led to a decline in the resident's general health, transfer to the acute hospital and death. Findings: During a review of Resident 1's clinical record on [DATE], the record reflected that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was noted to be alert and oriented upon admission. During a review of the facility physician's "History and Physical" dated February 13, 2013, it reflected that Resident 1 was capable of making decisions. During a review of Resident 1's MDS (minimum data set, an assessment tool) CAA (Care Area Assessment Documentation Notes ) dated February 18, 2013, reflected that Resident 1 was right hand dominant, required assistance with all ADLs (activities of daily living such as eating, oral care, and bathing). During an interview with CNA (Certified Nursing Assistant) 1 , on [DATE] at 3:30 PM, the CNA stated that Resident 1 had been depressed. She further stated that the resident refused to eat multiple times and said that the licensed nurses were aware of all this. During a review of Resident 1's care plan titled "Nutrition", dated February 9, 2013, the care plan documented the following interventions, assist with meals, encourage fluids and observe skin turgor (Skin turgor is a sign commonly used to assess the degree of fluid loss or dehydration), mucous membranes (lining of tissue in mouth such as dry lips), urine color and odor, monitor weight weekly x 4 then monthly, and monitor PO (orally) intake tid (three times a day). During a review of the RD (Registered Dietician) admission assessment note dated February 14, 2013, it reflected that the dietician had assessed the resident as being "at risk for dehydration (excessive loss of body water)." It further indicated that Resident 1 needed ,[DATE] cc of fluid intake per day. (1 glass of water =240 cc . Resident 1 required 9 to 10 glasses of fluid a day) Review of the resident's Nursing Assistant Flow Sheet for the month of February 2013, reflected that the resident drank very little fluids during his stay in the facility: February 9, 2013 (date of admission) = took in 240 cc (cubic centimeters). February 10, 2013= 600 cc February 11, 2013= 940 cc February 12, 2013= 600 cc February 13, 2013= 600 cc February 14, 2013= 320 cc February 15, 2013= 400 cc February 16, 2013= 600 cc February 17, 2013= 300 cc February 18, 2013= 600 cc February 19, 2013= 240 cc February 20, 2013= 480 cc February 21, 2013= 600 cc February 22, 2013= 240 cc February 23, 2013= 240 cc February 24, 2013= 250 cc February 25, 2013= 240 cc February 26, 2013= 120 cc Further review showed that Resident 1 had an average of 422.77 cc of fluids/ day (only drank two glasses of water a day) (RD recommendation ,[DATE] cc of fluid intake per day= 9 to 10 glasses of water a day) from February 9, 2013 through February 26, 2013. No other documentation was found in the clinical record showing that the physician had been notified that Resident 1 had very poor fluid intake/day, and that Resident 1 was only taking 25 % of the total amount of fluids that was recommended by the RD. The DON (Director of Nursing) verified the finding during the record review. During a review of the facility policy and procedure titled "Hydration" dated February 2013, it reflected the following, "It is the policy of this facility that all residents receive an adequate amount of fluids during the 24 hour day in accordance with each resident's individual needs and within the limitations set by physician orders as applicable. During an interview with the DON on [DATE] at 9:45 AM, the DON stated that due to the resident's poor fluid intake, the resident intake and output should have been monitored. The DON confirmed that the resident only drank the average of 25 % of fluids/day, from the amount of ,[DATE] cc/day per the RD recommendation. The DON stated that Resident 1 did not take in adequate fluids intake/day. During a review of Resident 1's pre admission laboratory (lab) result, dated February 8, 2013, Resident 1's BUN (blood urea nitrogen, a lab value that used to determine kidney function and hydration) was 12 (normal range is ,[DATE] mg/dl) mg/dl (milligrams per deciliter a unit of measurement), and blood creatinine level (a lab value used to determine hydration and kidney function) was 0.8 mg/dl (normal range is 0XXX,[DATE].3 mg/dl). During a review of the Nurses Progress Notes, dated February 26, 2013, documented that Resident 1 had a change of condition with labored breathing, was less responsive and transferred to the acute hospital at 5:07 PM. During a review of the "Patient Transfer and Referral Record", dated February 26, 2013, documented that Resident 1 was "lethargic (state of being drowsy)", labored breathing..." During a review of the acute hospital record "Emergency Department Chart", dated February 26, 2013, documented that Resident 1 expired on [DATE] at 5:50 PM. During a review of Resident 1's autopsy results dated [DATE], documented the following [MEDICATION NAME] (the fluid in the eyeball) lab values: urea nitrogen (a lab value that used to determine kidney function and hydration) greater than 100 mg/dl(milligram per deciliter, unit of measurement) (normal ,[DATE] mg/dl ), and Creatinine (a lab value used to determine hydration and kidney function) 6.3 mg/dl (normal 0XXX,[DATE].3 mg/dl ). Urea Nitrogen and Creatinine values are indicative of dehydration.

Based on observation, interview and record review, the facility failed to follow policy to: 1. Ensure that toileting schedules were implemented to meet the needs for 1 of 16 sampled residents (Resident 1). Resident 1, a confused resident with a history of falls, had 2 unwitnessed falls in the facility on 5/16/11 and again on 6/3/11 while attempting to go the bathroom unassisted. On the 6/3/11 fall, the resident sustained [REDACTED]. 2. The facility failed to secure an oxygen tank in room 308. During the initial tour of the facility on 6/13/11, an oxygen tank in room 308 was not protected in an oxygen tank holder. This had the potential to cause harm if the oxygen tank fell on to the floor which could result to injuries to nearby residents in a universe of 80. Findings: 1. On 6/14/11, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a comprehensive assessment of the resident) completed on 3/30/11, indicated that Resident 1 understood and was able to understand others. The resident required extensive assistance (staff provides weight bearing support) with 2 person physical assist with transfers. A review of the resident's fall re-assessments completed on 3/29/11, 4/5/11, 5/16/11 and 6/3/11 indicated that Resident 1 had fallen 2 times within 3 months of admission, was forgetful and needed the wheel chair and walker for ambulation. Resident 1 scored 90 to 95 points on each of the fall risk assessments. According to the facility ' s fall risk assessment, a score of 40 or more indicated that the resident was at high risk for falls. The care plan titled, " Falling star program, high risk " (a program designed to increase staff awareness of residents who are at highest risk for falls and to implement team oriented approaches to help reduce falls), initiated on 3/23/11, included the following interventions: a. Body monitors (a box with an alarm that is attached to the bed frame or the wheel chair handle and has a string with a clip that is connected to the box alarm. The clip end is attached to a part of the resident ' s clothing. Once the resident move and the string disconnects from the alarm box, an alarm activates to notify staff of the resident movement) when in bed and wheel chair b. Provide education for safe transfers, calling for assistance, use of proper fitting shoes or non-skid socks c. Frequent visual checks d. One person assist with transfers e. Back to bed after meals and or rest periods The resident was found on the floor on 5/16/11. The following interventions were added to the initial care plan: f. Infrared monitor (a sensor that is connect to the bed frame. Once motion is detected within a certain range of the sensor, it alarms and notifies staff of the resident movement) on the bed g. Encourage to call for assist to use the bathroom h. 5/18/11, Restorative Nursing Assistant (RNA) for ambulation 6 x (times) a week, X (for) 90 days i. 5/20/11, weight bearing as tolerated with walker j. Fall precautions The nurse's progress notes dated 5/16/11 at 10:10 AM was reviewed on 6/14/11. It indicated that the RNA staff, found Resident 1 sitting on the floor halfway to the bathroom. The resident stated that she was trying to go to the bathroom, lost her balance and slid along the wall to the floor. An abrasion, 11 x 4 centimeters (cm), was noted to the middle section of the resident ' s back along with a 1 x 1 cm skin tear to the resident ' s right thumb. Resident 1 was non-complaint with the body monitor. The nurse's progress notes dated 5/17/11 at 11:30 AM, was reviewed on 6/14/11. It indicated, "New order for infrared monitor to bed due to non-complaint with body monitor". A review of the nurses notes dated 5/18/11 at 10:35 AM and on 5/19/11 at 10:05 AM included, " Resident alert with confusion as per usual ". A review of the physical therapy summary report dated 5/13/11 indicated that therapy services continued to be required to address the following deficits: a. Decreased strength b. Poor standing posture c. Decreased activity tolerance d. Decreased mobility On 6/15/11 at 1:55 PM, an interview was conducted with RNA 1 who responded to Resident 1's fall. RNA 1 stated that she was walking down the 200 hallway when she heard a crashing sound in Resident 1's room. RNA 1 stated that when she entered Resident 1's room, the resident was sitting on top of a folding chair and against the wall. Resident 1 stated that she slid out of the wheel chair and lost her balance while trying to go to the bathroom. RNA 1 stated that the body alarm was not alarming and that she could not remember seeing a body alarm. On 6/16/11 at 11:45 AM, an interview was conducted with LVN 1 who was responsible for Resident 1 at the time of the fall. LVN 1 stated that when she arrived at Resident 1's room, the resident was sitting on the floor next to the wall. LVN 1 stated that the body monitor was attached to the wheel chair but was not activated. LVN 1 stated, " The resident could have removed it " . The care plan titled, " Found on floor " , initiated 5/16/11 included the following interventions: a. Treatment as ordered. b. Shadow check (check the resident whereabouts every 15 minutes x 72 hours). c. 5/17/11, Body monitor in bed and wheel chair. d. Infrared on bed, resident removes body monitor. The facility was aware that Resident 1 was capable of taking off the body monitor when the resident was in the wheel chair. The fall care plan initiated on 5/17/11, had the same intervention for a body monitor when the resident was in the wheel chair. A review of the physical restraint assessment, completed by the Interdisciplinary Team (IDT) on 5/18/11, included the following: A. fell at home with fracture. fell on [DATE] with skin tear to right thumb and abrasion to left thoracic spine (left side of the back). B. Body monitor on bed and wheel chair. Call for assistance sign on the bathroom door. Infrared on bed. Resident removes body monitor. C. Resident over-estimates limitations and transfers herself without calling for help. D. Resident was evaluated by physical or occupational therapist and goals were met. Resident discharged to RNA program. E. Restraint or alternative recommendations: Continue with body monitor in bed and wheel chair. Infrared monitor on bed. The IDT on 5/18/11 identified that Resident 1 was removing the body monitor. There were no new interventions documented to be used when the resident was up in the wheel chair. A review of the licensed nurse ' s progress notes, dated 5/31/11 at 3:15 PM, indicated that Resident 1 complained of frequency in urination. The physician ordered a urine specimen to test for a bladder infection. The result was positive for urinary tract infection. A review of the care plan titled, " Cough and complaint of frequency with urination, UTI 6/1/11 " , initiated on 5/31/11, had no instructions for the staff or interventions regarding toileting for the urinary frequency for the resident. The nurses progress notes, dated 6/3/11 at 7:30 PM, was reviewed on 6/14/11. The notes indicated that Resident 1 was found lying on her right side on the floor by the foot of the bed. The infrared monitor was sounding off in the darkened room. Resident 1 stated that she slid out of her wheel chair while trying to go to the bathroom. Lacerations were observed to Resident 1 ' s right shoulder and right elbow. Resident 1 complained of pain to the right hip on ambulation. Resident 1 was transported to the acute care hospital for evaluation. A review of the acute care hospital emergency room assessment completed on 6/3/11 at 8:40 PM indicated that Resident 1 complained of right hip injury. The right leg was shorter than the left leg. The right hip was not straight and had moderate tenderness. Range of motion (movement) was limited to the right hip due to pain. X-rays indicated that the right hip was fractured (broken). On 6/15/11 at 8:30 AM, an interview was conducted with Resident 1. Resident 1 was alert and oriented to person and place. Resident 1 stated that she was forgetful and could not recall how the falls occurred. Resident 1 stated, " I used to be a professor, now I cannot get anything straight in my head ". On 6/17/11, the policy titled, " Fall management Program " , version 6/9/09 was reviewed and included the following: " 15. Members of the IDT will review fall reports, review contributing risks factors, and investigate as needed to assist in revising the plan of care to reduce the risk of further falls. 16. Residents with repeat falls may be considered for high risk identification program. (Refer to policy for the falling leaf/star program) " . The facility policy titled, " Falling star, frequent fall reduction program " , version 6/9/09 was reviewed and included the following: ? " More frequent visual checks ? Assessment for bowel and bladder retraining, an individualized " scheduled toileting " or " prompted voiding " plan ? Resident is " last one up, first one down " for assistance to and from meals or activities. " An interview was conducted with the Director of Nursing (DON) on 6/16/11 at 11:50 AM. The DON stated that the Interdisciplinary Team (IDT) meeting was conducted on 5/18/11 following Resident 1's fall on 5/16/11. The IDT recommendations were reviewed: Continue with body monitor in bed and wheel chair; " call for assist " sign on the bathroom door; infrared monitor on bed; resident removes body monitor and does not call for help. The DON stated that the IDT should have evaluated Resident 1 for a different form of restraint due to the resident's confusion, had a history of [REDACTED].. The DON stated, "We should have tried something different. We should have evaluated Resident 1 for a self- releasing seat belt with an alarm. Those body alarms are not effective, by the time the staff responds to the alarm, the resident is already on the floor". The DON stated that Resident 1 was placed on 15 minutes check for 72 hours following the fall on 5/16/11. During the same interview, the DON confirmed that the care plan had no interventions for toileting, addressing Resident 1's urinary frequency. The DON acknowledged that Resident 1 needed to use the bathroom again when she fell for the second time in the facility. The DON stated that Resident 1 should have been placed on a toileting scheduling due to urinary frequency and should have been on a toileting schedule because the resident was a high risk for fall. On 6/17/11 at 9:10 AM, an interview was conducted with LVN 2 via the telephone. LVN 2 was responsible for Resident 1's care at the time of the fall on 6/3/11. LVN 2 stated that when she entered Resident 1's room, the resident was lying on the floor towards the end of the bed. LVN 2 stated that the infrared monitor on the bed was sounding. Paramedics were called and provided first aid to the skin tear on the right shoulder. Resident 1 complained of pain on ambulation and the paramedics placed Resident 1 onto the gurney. Resident 1 was alert with confusion and was transported to the acute care hospital emergency room . On 6/17/11 at approximately 11:50 AM, an interview was conducted via the telephone with CNA 1. CNA 1 was assigned to care for Resident 1 at the time of the fall on 6/3/11. CNA 1 stated that when she came out of another resident's room, Resident 1's call light was on and the infrared monitor on the bed was sounding. CNA 1 entered Resident's 1 room and observed the resident on the floor by the foot of the bed. Resident 1 was alert and stated that she got out of the wheel chair to go to the bathroom and fell on the floor. CNA 1 stated that she notified LVN 2 of the resident fall. CNA 1 stated that this was the second time that she was assigned to care for Resident 1 and that the resident was alert with confusion at times. CNA 1 stated that Resident 1 had eaten dinner in her room and was sitting in her wheel chair. CNA 1 stated that she was not sure and could not remember anything about the body alarm. CNA 1 stated that she remembered turning off the alarm from the bed infrared monitor. CNA 1 stated that she did not know how long Resident 1's call light was on prior to the resident fall. CNA 1 acknowledged that she had not assisted Resident 1 back to bed immediately after dinner per the "Falling Star Program". CNA 1 stated that the resident needed assistance to use the bathroom. The IDT failed to assess and implement new interventions to prevent further falls for Resident 1. Staff was aware that Resident 1 took off the body monitor when she was up in the wheel chair, did not call for assistance and had fallen on 5/16/11, in the facility. The facility did not implement any new interventions to prevent further falls for Resident 1 when the resident was up in the wheel chair. The facility did not follow the falling star frequent fall reduction program and put Resident 1, the first resident to bed after dinner. There was no documented evidence at the time of the fall on 6/3/11 for frequent visual checks for Resident 1. The facility failed to implement toileting interventions to address Resident 1's urinary frequency due to the bladder infection and per the falling star program. Resident 1 fell 2 times in the facility while trying to go to the bathroom. 2. During the initial tour of the facility on 6/13/11 at approximately 11:15 AM, an observation was made of an oxygen tank that was not in an oxygen tank holder in room 308. An interview conducted on 6/13/11 at approximately 11:15 AM with LVN 3, she confirmed the findings. The staff stated that the oxygen tank should have been secured in an oxygen tank holder to prevent it from falling on to the floor.